Nokea
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
- A. Encouraging fluids
- B. Providing frequent oral care
- C. Coughing and deep breathing
- D. Monitoring the red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Encouraging fluids. In a client with multiple myeloma, encouraging fluids is a priority intervention to prevent kidney damage from high calcium levels. Adequate hydration helps maintain renal function and prevents complications. Providing frequent oral care (Choice B) is essential for clients at risk of mucositis or oral infections, such as those undergoing chemotherapy. Coughing and deep breathing exercises (Choice C) are commonly used for clients at risk of respiratory complications, like postoperative patients. Monitoring the red blood cell count (Choice D) is important for conditions like anemia but is not the priority in a client with multiple myeloma, where fluid management is crucial.
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Gastric cancer is known to have numerous risk factors. Which of the following is not a risk factor?
- A. Diet high in sodium
- B. Diet with high amounts of chili garlic
- C. Smoking
- D. Diet high in fiber
Correct Answer: D
Rationale: A diet high in fiber is not a risk factor for gastric cancer; in fact, it is generally considered protective against cancers. High sodium intake (Choice A) has been associated with an increased risk of gastric cancer. Diets with high amounts of chili garlic (Choice B) may irritate the stomach lining, potentially contributing to the development of gastric cancer. Smoking (Choice C) is a well-established risk factor for various types of cancers, including gastric cancer.
A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?
- A. Assess the client's gait and balance.
- B. Ask the client about any changes in urinary symptoms.
- C. Document the report thoroughly.
- D. Inquire about the client's recent activities.
Correct Answer: A
Rationale: The correct action by the nurse is to assess the client's gait and balance. Severe low back pain in a client with a history of prostate cancer may indicate spinal cord compression, a serious complication. Assessing gait and balance can help determine if there is any spinal cord involvement, which requires immediate medical attention. Asking about changes in urinary symptoms (choice B) is important to assess for possible urinary obstruction, but assessing gait and balance takes precedence due to the risk of spinal cord compression. Documenting the report thoroughly (choice C) is essential but not the most immediate action needed. Inquiring about recent activities (choice D) is not as critical as assessing for spinal cord involvement.
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important?
- A. Assess blood pressure and pulse.
- B. Attach the client to a pulse oximeter.
- C. Have the client rate his or her pain.
- D. Facilitate urgent radiation therapy.
Correct Answer: A
Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.
The nurse is caring for a client following radical neck dissection and creation of a tracheostomy. Which assessment finding would indicate an immediate need for intervention?
- A. Frequent swallowing
- B. Presence of mucous membranes
- C. Bubbling in the water-seal chamber
- D. Inspiratory stridor
Correct Answer: D
Rationale: Inspiratory stridor is the correct answer as it suggests airway obstruction, a critical issue requiring immediate intervention. Frequent swallowing (choice A) is a common postoperative finding and does not indicate an immediate need for intervention. The presence of mucous membranes (choice B) is a normal finding and does not require immediate intervention. Bubbling in the water-seal chamber (choice C) of a chest tube drainage system is an expected finding and indicates proper functioning of the system, not an immediate need for intervention.
A patient with myelofibrosis is being treated with ruxolitinib. What should the nurse monitor to assess the effectiveness of this treatment?
- A. Blood pressure
- B. White blood cell count
- C. Hemoglobin and hematocrit
- D. Spleen size
Correct Answer: C
Rationale: Monitoring hemoglobin and hematocrit is essential to assess the effectiveness of ruxolitinib in treating myelofibrosis. Ruxolitinib works by inhibiting JAK1 and JAK2, which are involved in the signaling pathways that regulate blood cell production. Therefore, monitoring hemoglobin and hematocrit levels can provide valuable information on how well the drug is managing the disease. Blood pressure, white blood cell count, and spleen size are not direct indicators of the treatment's effectiveness in myelofibrosis.