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Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
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The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate 57 bpm
- B. SpO2 of 94% on room air
- C. Blood pressure in 1 mm/s
- D. Ankle brachial index of 0.65
Correct Answer: D
Rationale: An ankle-brachial index (ABI) of 0.65 is significantly below the normal range (0.9–1.3), indicating potential peripheral vascular disease (PVD) due to arterial insufficiency. This finding warrants further evaluation, especially given the client's symptoms of claudication (pain during exercise relieved by rest) and smoking history, which are risk factors for PVD. The other options€”heart rate, SpO2, and blood pressure€”are either normal or irrelevant in this context.
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
- A. Increased anteroposterior chest diameter.
- B. Underdeveloped neck muscles.
- C. Collapsed neck veins.
- D. Increased chest excursions with respiration.
Correct Answer: A
Rationale: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.
The nurse is caring for a client reporting an abrupt onset of severe pain associated with metastatic cancer. Which prescription should the nurse plan to administer?
- A. fentanyl via transdermal patch
- B. pregabalin
- C. ketorolac
- D. hydromorphone
Correct Answer: D
Rationale: Hydromorphone is appropriate for rapid relief of severe, acute cancer pain due to its fast-acting opioid properties.
A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
- A. Avoid cleaning the nares until swelling has subsided.
- B. Apply water-soluble jelly to lubricate the nares.
- C. Keep a nasal drip pad in place to absorb secretions.
- D. Use a bulb syringe to gently irrigate nares.
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.