Nokea
The nurse is caring for a client with a history of breast cancer.
- A. Which symptom should the nurse report immediately for a client with a history of breast cancer?
- B. Mild fatigue after chemotherapy.
- C. A new lump in the axillary region.
- D. Occasional nausea.
- E. Hair loss.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
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The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
- A. You should be emptying the pouch yourself.'
- B. Let me demonstrate to you how to empty the pouch.'
- C. What have you learned about emptying your pouch?'
- D. Show me what you have learned about emptying your pouch.'
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Some increase in the serum hemoglobin
- D. A little decrease in the serum potassium
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
A 35-year-old woman receiving metronidazole (Flagyl) 250 mg PO tid for 7 days.
Which of the following statements, if made by the woman, would indicate that teaching has been effective?
- A. I should take this medication between meals to increase absorption.'
- B. I shouldn't drink alcohol while I am taking this medication.'
- C. If I experience a metallic taste in my mouth while taking this mediation, I should notify the physician.'
- D. I should avoid strong sunlight while I am taking this medication.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been effective' indicates a correct statement. (1) given with meals to decrease GI upset (2) correct-causes Antabuse-like reaction of nausea and vomiting, headache, cramps, flushing (3) frequently seen, not a problem (4) sensitivity to sun not seen with this medication
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.