Nokea
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Vaginal bleeding.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.
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A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
- A. Inability to move toes.
- B. Cyanosis of toes.
- C. Complaints of cast tightness.
- D. Tingling of toes.
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
- A. Irrigate the tube with 30 mL of sterile saline every 4 hours.
- B. Keep the head of the bed elevated at 45 degrees.
- C. Check for tube placement every shift.
- D. Clamp the tube when ambulating the client.
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
- A. Resume normal diet immediately
- B. Report fever or yellowing of skin
- C. Avoid bathing for 2 weeks
- D. Lift heavy objects as tolerated
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Tremors.
Correct Answer: A,D
Rationale: Risperidone can cause weight gain and extrapyramidal symptoms like tremors, which the nurse should monitor.
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.