Nokea
The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
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When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying on the side
- D. Standing to shower
Correct Answer: D
Rationale: Standing to shower is least desirable post-below-the-knee amputation due to the risk of falls and weight-bearing on the stump, which could disrupt healing. Other positions are safer.
Which nursing intervention is most important after the client returns from the myelogram?
- A. Turning off the room's bright lights
- B. Withholding food and fluids for 12 hours
- C. Administering sedatives every 6 hours
- D. Encouraging a high fluid intake
Correct Answer: D
Rationale: A high fluid intake post-myelogram with water-soluble dye helps excrete the contrast, reducing the risk of complications like seizures or renal issues. Other interventions are less critical.
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol increases uric acid levels, worsening gout.
Which intervention for bladder emptying should the nurse plan to implement for a 14-year-old with a neurogenic bladder from an SCI with a lower motor neuron lesion?
- A. Intermittent catheterization
- B. Insertion of a retention catheter
- C. Insertion of a suprapubic catheter
- D. Giving an anticholinergic medication
Correct Answer: A
Rationale: Intermittent catheterizationelevation is preferred for neurogenic bladder due to lower motor neuron lesions to prevent urinary retention.
Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining normal weight reduces joint stress, especially in osteoarthritis.