Nokea
The most common issue associated with sleep disturbances in the hospitalized client with cancer is:
- A. Social.
- B. Nutritional.
- C. Cultural.
- D. Psychological.
Correct Answer: D
Rationale: Psychological factors, such as anxiety or fear related to cancer diagnosis and treatment, are the most common causes of sleep disturbances in hospitalized cancer patients.
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Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.
A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority.
- A. Administer morphine sulfate 2 mg I.V.
- B. Apply oxygen at 2 L via nasal cannula.
- C. Educate the client in anticipation of a thoracentesis.
- D. Coach the client on deep breathing exercise.
Correct Answer: B,A,C,D
Rationale: Oxygen (B) addresses immediate hypoxia, morphine (A) relieves pain and dyspnea, education for thoracentesis (C) prepares for definitive treatment, and deep breathing (D) supports respiratory function.
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
- A. Taking sitz baths several times a day.
- B. Applying a moist heat pack to the wound.
- C. Performing perineal irrigations.
- D. Packing the wound with sterile gauze.
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
- A. Hemoptysis.
- B. Focal ischemia.
- C. Petechiae.
- D. Hematuria.
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.