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The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) reduces metabolic demands and supports recovery in viral hepatitis. Increased fluids (B) are supportive but secondary. High-protein diets (C) or avoiding carbohydrates (D) are not indicated for hepatitis management.
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A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
- A. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
- B. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle.
- C. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
- D. Stay with the client during the first 15 minutes of infusion.
Correct Answer: D
Rationale: The nurse should stay with the client during the first 15 minutes of a blood transfusion, as this is the most likely time for a transfusion reaction to occur. Close monitoring allows for immediate intervention if a reaction is detected. Discontinuing the IV is only done if a reaction occurs, PRBCs should not be administered via a 20-gauge needle (a larger gauge is needed), and dextrose solutions are incompatible with PRBCs.
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
- A. Wearing a prosthesis during intimate moments.
- B. Avoiding discussions about her surgery with her partner.
- C. Focusing only on non-physical aspects of intimacy.
- D. Ignoring her concerns as they are temporary.
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
- A. Assess heart sounds.
- B. Obtain an order for blood cultures.
- C. Prepare for a paracentesis.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (D) improves breathing. Heart sounds (A), blood cultures (B), and paracentesis (C) are secondary.