Nokea
What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.
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The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
- A. Monitor daily weights and urine output.
- B. Permit unrestricted visitation by family and friends.
- C. Provide client education on medications and diet.
- D. Reduce pain and myocardial oxygen demand.
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
- A. Elevated red blood cell count.
- B. Decreased platelet count.
- C. Elevated white blood cell count.
- D. Elevated serum blood urea nitrogen concentration.
Correct Answer: C
Rationale: Diverticulitis, an inflammatory condition, typically causes an elevated white blood cell count due to infection or inflammation. Red blood cell count, platelet count, and blood urea nitrogen are not directly affected. CN: Physiological adaptation; CL: Analyze
The nurse is caring for a client who has been prescribed naproxen. Which condition in the client's medical history would require clarification with the primary healthcare provider (PHCP)?
- A. Rheumatoid arthritis (RA)
- B. Congestive heart failure (CHF)
- C. Osteoarthritis
- D. Psoriatic arthritis
Correct Answer: B
Rationale: Naproxen, an NSAID, can exacerbate congestive heart failure by causing fluid retention and increasing cardiac workload.