Nokea
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
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A client 24 hours post-appendectomy reports sudden sharp abdominal pain and a fever of 101.2°F (38.4°C). The nurse's first action should be:
- A. Administer an antipyretic.
- B. Notify the surgeon.
- C. Encourage ambulation.
- D. Apply a warm compress.
Correct Answer: B
Rationale: Sudden sharp pain and fever post-appendectomy suggest a complication like abscess or peritonitis. Notifying the surgeon ensures prompt evaluation and intervention.
The nurse is checking the laboratory results of a 52-year-old client with colon cancer admitted for further chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider?
- A. Blood glucose level of 95 mg/dL.
- B. Total cholesterol level of 102 mg/dL.
- C. Hemoglobin level of 12.3 mg/dL.
- D. Albumin level of 2.8 g/dL.
Correct Answer: D
Rationale: A low albumin level (2.8 g/dL) indicates malnutrition, which is concerning given the client's significant weight loss and needs to be reported for nutritional intervention.
In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? The client will:
- A. Have normalized albumin levels.
- B. Return to ideal body weight.
- C. Gain 1 lb every 2 weeks.
- D. Maintain current weight.
Correct Answer: D
Rationale: Maintaining current weight is a realistic goal for a client with advanced liver cancer and poor nutrition, as weight gain or normalized albumin may be unachievable due to disease progression.
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?
- A. Cholelithiasis.
- B. Hepatitis.
- C. Irritable bowel syndrome.
- D. Diabetes mellitus.
Correct Answer: D
Rationale: Chronic pancreatitis damages pancreatic tissue, impairing insulin production and increasing the risk of diabetes mellitus (D). Cholelithiasis (A), hepatitis (B), and irritable bowel syndrome (C) are less directly related.