Nokea
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
- A. Assisting with her daily hygiene activities.
- B. Lying flat in bed.
- C. Walking in the hall.
- D. Sitting all afternoon in her room.
Correct Answer: D
Rationale: Prolonged sitting stresses the surgical site and is contraindicated post-laminectomy.
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The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation?
- A. Combination chemotherapy is used to interrupt cell growth cycle at different points.'
- B. Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.'
- C. Combination chemotherapy is used to decrease resistance.'
- D. Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent.'
Correct Answer: B
Rationale: Combination chemotherapy targets cancer cells at different cell cycle stages, reduces resistance, and minimizes toxicity by using lower doses of multiple drugs. It does not treat side effects; supportive care does. This statement indicates a need for further explanation.
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
- A. Pinkish red.
- B. Dark yellow-orange.
- C. Clear.
- D. Green.
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?
- A. Oxygen at 4 L per nasal cannula.
- B. Potassium 40 mEq PO now.
- C. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour.
- D. NaHCO‚ƒ 75 mEq IV.
Correct Answer: C
Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.
A client with bladder cancer receives intravesical chemotherapy. The nurse should:
- A. Monitor for hematuria.
- B. Restrict fluids.
- C. Administer pain medication.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.