Nokea
You are caring for a hospice client who is at the end of life. Based on this client's signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client?
- A. The client will be free of constipation
- B. The client will remain free of pain and distress
- C. The administration of an antiemetic to prevent vomiting and further dehydration
- D. The administration of an enema to correct the constipation
Correct Answer: B
Rationale: Given the client's comatose state and imminent death, the priority is to maintain comfort. Ensuring the client remains free of pain and distress is the most appropriate outcome, as aggressive interventions like enemas or antiemetics are less relevant in this context.
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A client with a diagnosis of breast cancer is prescribed letrozole (Femara). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of letrozole requiring immediate reporting.
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Respiratory distress.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
- A. A quiet environment promotes more rapid healing of the aneurysm.
- B. Clients with aneurysms need isolation to cope with photosensitivity.
- C. Reduced environmental stimuli are needed to prevent aneurysm rupture.
- D. The client has disorganization of thoughts and feelings and needs reduced activity.
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Metallic taste.
- C. Lactic acidosis symptoms.
- D. Weight gain.
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.
A client with a history of chronic lymphocytic leukemia is admitted with fatigue and pallor. Which laboratory value should the nurse monitor?
- A. Hemoglobin
- B. White blood cell count
- C. Platelet count
- D. All of the above
Correct Answer: D
Rationale: Chronic lymphocytic leukemia can cause anemia (low hemoglobin), infection risk (abnormal WBCs), and bleeding risk (low platelets), requiring monitoring of all values.