Nokea
The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places priority on discussing which risk factor with this client?
- A. Age older than 30 years
- B. High-fat and low-fiber diet
- C. Distant relative with colorectal cancer
- D. Personal history of ulcerative colitis or gastrointestinal polyps
Correct Answer: B
Rationale: Clients should be aware of modifiable risk factors as part of general health maintenance and primary disease prevention. Modifiable risk factors are those that can be reduced and include a high-fat and low-fiber diet. Common risk factors for colorectal cancer that cannot be changed include age older than 40 years, first-degree relative with colorectal cancer, and history of bowel problems such as ulcerative colitis or familial polyposis.
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A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
The nurse is caring for a client with a chest tube. Which finding indicates a potential complication?
- A. Continuous bubbling in the water seal chamber.
- B. Fluctuation in the water seal with breathing.
- C. Serosanguineous drainage.
- D. Pain at the insertion site.
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate attention.
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.