Nokea
The nurse assesses a postoperative mastectomy client and notes the breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Obtain arterial blood gases
- C. Increase O2 from 2-3 L/min
- D. Remove the postoperative dressing to check for bleeding
Correct Answer: A
Rationale: Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. Arterial blood gases are not indicated because there is no other information indicating impending danger. Increasing O2 rate is not indicated without additional information. Removing the dressing is not indicated without additional information.
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A client with a history of testicular cancer is admitted with complaints of back pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Back pain in testicular cancer may indicate metastasis to retroperitoneal lymph nodes, so monitoring for metastasis is the priority.
The client with chronic renal failure is prescribed aluminum hydroxide (Amphojel). The purpose of this medication is to:
- A. Reduce serum phosphate levels
- B. Increase urine output
- C. Prevent gastric ulcers
- D. Promote bowel elimination
Correct Answer: A
Rationale: Aluminum hydroxide binds dietary phosphate in the gut, reducing serum phosphate levels in chronic renal failure, where kidneys cannot excrete phosphate. It does not affect urine output, ulcers, or bowel elimination directly.
While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor.
- B. Avoid sun exposure while using the herbal supplement.
- C. Purchase only those brands with FDA approval.
- D. Increase daily intake of vitamin E.
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by inhibiting platelet aggregation, so clients should report signs of bruising or bleeding to their doctor.
The physician has prescribed Zyvox (linezolid) for a patient with VRE. The concurrent use of which medication may result in serotonin syndrome?
- A. Nexium (esomeprazole)
- B. Zoloft (sertraline)
- C. Lipitor (atorvastatin)
- D. Zyrtec (cetirizine)
Correct Answer: B
Rationale: Linezolid, a monoamine oxidase inhibitor, can cause serotonin syndrome when combined with SSRIs like Zoloft (sertraline), due to excessive serotonin accumulation. Nexium, Lipitor, and Zyrtec do not interact in this way.
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Correct Answer: C
Rationale: Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. The side effects of morphine sulfate include respiratory depression. Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.