Nokea
The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for:
- A. Alteration in renal perfusion
- B. Electrolyte imbalance
- C. Ineffective coping
- D. Wound infection
Correct Answer: A
Rationale: Post-aortic aneurysm repair, assessing renal perfusion is critical, as the surgery may involve clamping the aorta, risking renal ischemia. Reduced urine output or elevated creatinine indicates renal compromise. Electrolyte imbalance, coping, and infection are secondary concerns.
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The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation?
- A. Combination chemotherapy is used to interrupt cell growth cycle at different points.'
- B. Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.'
- C. Combination chemotherapy is used to decrease resistance.'
- D. Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent.'
Correct Answer: B
Rationale: Combination chemotherapy targets cancer cells at different cell cycle stages, reduces resistance, and minimizes toxicity by using lower doses of multiple drugs. It does not treat side effects; supportive care does. This statement indicates a need for further explanation.
What is the rationale that supports multidrug treatment for clients with tuberculosis?
- A. Multiple drugs potentiate the drugs' actions.
- B. Multiple drugs reduce undesirable drug adverse effects.
- C. Multiple drugs allow reduced drug dosages to be given.
- D. Multiple drugs reduce development of resistant strains of the bacteria.
Correct Answer: D
Rationale: Multidrug therapy for tuberculosis prevents the development of resistant bacterial strains by targeting different aspects of bacterial growth. Potentiation, reduced adverse effects, or lower dosages are not the primary rationale.
The nurse is reviewing a client's preoperative checklist and notes the client has not voided in the last 6 hours. The nurse should:
- A. Insert a urinary catheter.
- B. Encourage the client to void before transport.
- C. Notify the anesthesiologist.
- D. Document the finding and proceed.
Correct Answer: B
Rationale: Encouraging the client to void prevents bladder distention during surgery and reduces the need for catheterization, which carries infection risks.
A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.