Nokea
The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer?
- A. Individualize the pain medication regimen for the client.
- B. Select medications that are least likely to lead to addiction.
- C. Administer pain medication as soon as the client requests it.
- D. Change pain medications periodically to avoid drug tolerance.
Correct Answer: A
Rationale: Individualizing the regimen ensures effective pain control tailored to the client's needs, considering cancer pain's variable nature.
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The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
- A. Newborns cannot hear well until they are at least 6 weeks old.
- B. Her concern is unfounded because hearing problems are rare in newborns.
- C. The majority of states now mandate that newborns undergo a screening test for hearing.
- D. The mother can test the baby's hearing by clapping her hands 24 inches from the infant's head.
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypocalcemia.
- C. Hyponatremia.
- D. Hypermagnesemia.
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring.
The nurse is teaching a client with osteoporosis about calcium supplements. Which instruction is correct?
- A. Take calcium with a large meal.
- B. Avoid taking calcium with vitamin D.
- C. Take calcium at bedtime only.
- D. Split the dose if taking more than 500 mg.
Correct Answer: D
Rationale: Splitting doses above 500 mg improves absorption and reduces gastrointestinal side effects.
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
- A. Heart rate
- B. Breath sounds
- C. Blood pressure
- D. Activity tolerance
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
A client with a history of heart failure is admitted with pulmonary edema. The nurse should administer which of the following medications as prescribed? Select all that apply.
- A. Furosemide (Lasix).
- B. Digoxin (Lanoxin).
- C. Nitroglycerin.
- D. Morphine.
- E. Aspirin.
Correct Answer: A, C, D
Rationale: Furosemide reduces fluid overload, nitroglycerin decreases preload, and morphine relieves anxiety and preload in pulmonary edema.