Nokea
The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
You may also like to solve these questions
In which of these do you see clue cells?
- A. trichomonas vaginalis
- B. bacterial vaginosis
- C. candida
- D. HSV 2
Correct Answer: B
Rationale: Clue cells BV's fishy flag, not trich's swim, candida's yeast, HSV's sores, or syphilis' chancre. Nurses scope this chronic hint.
Regarding HIV/AIDS
- A. Shingles, seborrhoeic dermatitis and recurrent HSV infections are typical of early infection
- B. A CD4 count of 1.0 x 10^9/L is associated with late stage AIDS
- C. Pre and post test counselling for HIV serology is now no longer mandatory
- D. Pneumococcus is a more likely pathogen than TB in AIDS patients with pneumonia
Correct Answer: D
Rationale: HIV early skin woes, CD4's units flop, counseling holds, TB trumps pneumococcus, toxo hits brain. Nurses chase this chronic lung truth.
After receiving the hand-off report, which client should the oncology nurse see first?
- A. Client who is afebrile with a heart rate of 108 beats/min
- B. Older client on chemotherapy with mental status changes
- C. Client who is neutropenic and in protective isolation
- D. Client scheduled for radiation therapy today
Correct Answer: B
Rationale: In oncology nursing, prioritizing care is critical due to the complexity of cancer patients' conditions. An older client on chemotherapy with mental status changes is the priority because this could signal sepsis or infection, especially since chemotherapy-induced neutropenia often masks typical signs like fever in the elderly. Mental confusion might be the only early clue, and delayed assessment could lead to rapid deterioration or death. A heart rate of 108 beats/min without fever suggests tachycardia, possibly from dehydration or anxiety, but it's less urgent without other red flags. A neutropenic client in isolation needs monitoring, but no acute change is noted. The client scheduled for radiation has a planned treatment, not an immediate crisis. Assessing the older client first allows the nurse to rule out or address a life-threatening issue, aligning with the principle of prioritizing unstable patients in acute care settings.
The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?
- A. Salvage surgery
- B. Palliative surgery
- C. Prophylactic surgery
- D. Reconstructive surgery
Correct Answer: C
Rationale: A bilateral mastectomy here is prophylactic removing nonvital breasts to prevent cancer in a high-risk patient with a positive tumor marker and family history. It's about risk reduction, not treatment of existing disease. Salvage surgery tackles recurrence after a less aggressive initial approach, like resecting a regrown tumor. Palliative surgery eases symptoms (e.g., pain from obstruction) in advanced cases, not prevention. Reconstructive surgery restores form or function post-treatment, like breast reconstruction after curative mastectomy. Prophylactic fits this preemptive strike, driven by genetic or familial risk (e.g., BRCA mutations), a growing trend in oncology to outpace cancer's onset, guided by nurses supporting informed, tough choices.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
- A. Generalized muscle aches
- B. Crackles heard at the lung bases
- C. Complaints of nausea and anorexia
- D. Oral temperature of 100.6°F (38.1°C)
Correct Answer: B
Rationale: IL-2 can spark capillary leak crackles at lung bases signal pulmonary edema, an emergency needing fast action over aches , nausea , or low fever , all common. Nurses in oncology flag this fluid in lungs kills quick, demanding stat calls.