Nokea
The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .
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The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions should the nurse prioritize?
- A. Encourage arm exercises on the affected side.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility post-mastectomy. Options B, C, and D are secondary.
A client admitted for regulation of her insulin dosage. The client takes 15 units of Humulin N insulin at 8 AM every day.
At 4 PM, which of the following nursing observations would indicate a complication from the insulin?
- A. Acetone odor to the breath, polyuria, and flushed skin.
- B. Irritability, tachycardia, and diaphoresis.
- C. Headache, nervousness, and polydipsia.
- D. Tenseness, tachycardia, and anorexia.
Correct Answer: B
Rationale: Strategy: Determine the cause of each symptom and how it relates to hypoglycemia. (1) signs of hyperglycemia (2) correct-Humulin N insulin is an intermediate-acting insulin that peaks from eight to twelve hours after administration; this is when signs and symptoms of hypoglycemia will occur (3) signs of hyperglycemia (4) signs of hyperglycemia
The nurse is teaching a client with a new diagnosis of heart failure about furosemide (Lasix). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle cramps to my doctor.
- B. I should take this medication in the morning.
- C. I should eat foods high in potassium.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping furosemide when feeling better is incorrect, as heart failure requires lifelong treatment to manage fluid overload. Options A, B, and C are correct: muscle cramps may indicate hypokalemia, morning dosing minimizes nocturia, and potassium-rich foods are recommended.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.