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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
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A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
Which assessment is most important for a client with a traumatic brain injury?
- A. Glasgow Coma Scale.
- B. Blood glucose levels.
- C. Electrolyte panel.
- D. Pain assessment.
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.
- A. Consume three regularly-spaced meals per day.
- B. Eat a diet with high carbohydrate foods with each meal.
- C. Reduce fluids with meals, but take them between meals.
- D. Obtain adequate amounts of protein and fat in each meal.
- E. Eat in a relaxing environment.
Correct Answer: C,D,E
Rationale: To avoid dumping syndrome, clients should reduce fluids with meals, ensure adequate protein and fat, and eat in a relaxing environment. Three meals a day and high-carbohydrate foods can exacerbate symptoms.
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PCO2 62; PO2 70; HCO3 34. The nurse should:
- A. Apply a 100% non-rebreather mask.
- B. Assess the vital signs.
- C. Reposition the client.
- D. Prepare for intubation.
Correct Answer: B
Rationale: The ABG shows compensated respiratory acidosis (normal pH, high PCO2, high HCO3) with mild hypoxemia (PO2 70). Assessing vital signs evaluates stability before escalating care. A non-rebreather mask or intubation is premature. Repositioning may help but is less urgent.