Nokea
The nurse is working with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. Which of the following is an appropriate nursing intervention?
- A. Refer the client to a community support group after discharge from the rehabilitation unit.
- B. Make certain that a family member is present for the rehabilitation sessions.
- C. Provide positive reinforcement for skills achieved.
- D. Inform the client of rehabilitation plans made by the rehabilitation team.
Correct Answer: C
Rationale: Providing positive reinforcement for achieved skills encourages the client's motivation and independence in activities of daily living.
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A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
- A. Use of loperamide (Imodium).
- B. Fluid restriction.
- C. Low fiber, bland diet.
- D. Bowel regimen.
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:
- A. Use blow bottles.
- B. Turn in bed.
- C. Take deep breaths.
- D. Cough.
Correct Answer: C
Rationale: Deep breathing exercises post-hypophysectomy help expand lungs and prevent atelectasis, reducing respiratory complications.
The nurse is checking the laboratory results on a 52-year-old client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed?
- A. Blood glucose.
- B. Total cholesterol.
- C. Hemoglobin.
- D. Low-density lipoprotein (LDL) cholesterol.
Correct Answer: A
Rationale: Elevated blood glucose in type 1 diabetes indicates poor glycemic control, requiring immediate management to prevent complications like ketoacidosis.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.