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[Audio] 1. A client is being discharged and needs instructions on wound care. When planning to teach the client, the nurse should: a. identify the client's learning needs and learning ability. b. identify the client's learning needs and advise him on what to do. c. identify the client's problems and make the appropriate referral. d. provide pamphlets or videotapes for ongoing learning..

[Audio] Answer is A. Identify the client's learning needs and learning ability..

[Audio] Rationale: To provide the most appropriate teaching, the nurse first needs to identify what the client needs to know and determine the client's educational level and learning ability..

[Audio] 2. A client is requesting a second opinion. The nurse who supports and promotes the client's rights is acting as the client's: a. teacher. b. adviser. c. supporter. d. advocate..

[Audio] Answer is D. Advocate.. Graphical user interface, text, application Description automatically generated.

[Audio] Rationale: The nurse's role as client advocate involves actively promoting clients' rights to make decisions and choices.

[Audio] 3. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? a) peasb) cauliflowerc) low-fat yogurtd) processed oat cereals.

[Audio] Answer is D. processed oat cereals. Graphical user interface, text, application Description automatically generated.

[Audio] Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content..

[Audio] 4. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?a) twitchingb) negative Trousseau's signc) hypoactive bowel soundsd) hypoactive deep tendon reflexes.

[Audio] Answer is A: Twitching.. Graphical user interface, text, application Description automatically generated.

[Audio] Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea..

[Audio] 5. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?a) sodium level of 145 mEq/Lb) potassium level of 3.0 mEq/Lc) magnesium level of 2.0 mg/dLd) phosporus level of 4.0 mg/dL.

[Audio] Answer is B. potassium level of 3.0 mEq/L..

[Audio] Rationale: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options A, C, and D identify normal laboratory values. Option B identifies the presence of hypokalemia..

[Audio] 6. The nurse teaches skin care to the client receiving external radiation therapy. Which of the following statements, if made by the client, would indicate the need for further instruction?a) I will handle the area gentlyb) I will avoid the use of deodorantsc) I will limit sun exposure to 1 hour dailyd) I will wear loose-fitting clothing.

[Audio] Answer is C. I will limit sun exposure to 1 hour daily..

[Audio] Rationale: The client needs to be instructed to avoid exposure to the sun. Options A, B, and D are accurate measures in the care of a client receiving external radiation therapy..

[Audio] 7. A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which of the following is an early sign of this oncological emergency?a) cyanosisb) arm edemac) periorbital edemad) mental status changes.

[Audio] Answer is C. periorbital edema. Graphical user interface, text, application Description automatically generated.

[Audio] Rationale: Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs..

[Audio] 8. A nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which of the following is a serious late sign of this oncological emergency?a) headacheb) dysphagiac) constipationd) electrocardiographic changes.

[Audio] Answer is D. electrocardiographic changes..

[Audio] Rationale: Hypercalcemia is a late manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave..

[Audio] 9. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client states:a) I should avoid blowing my noseb) I may need a platelet transfusion if my platelet count is too lowc) I'm going to take aspirin for my headache as soon as I get home. I will count the number of pads and tampons I use when menstruating.

[Audio] Answer is C. I'm going to take aspirin for my headache as soon as I get home. I will count the number of pads and tampons I use when menstruating.

[Audio] Rationale: During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. Option C describes an incorrect statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity, thus further teaching is needed..

[Audio] 10. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone ( SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that applya) radiationb) chemotherapyc) increased fluid intaked) serum sodium levelse) decreased oral sodium intakef) medication that is antagonistic to antidiuretic hormone.

[Audio] Answers are radiation, chemotherapy, serum sodium levels, medication that is antagonistic to antidiuretic hormone..

[Audio] Rationale: Cancer is a common cause of syndrome of inappropriate antidiuretic hormone ( SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal..

[Audio] 11. A nurse is caring for a client with an internal radiation implant. Which of the following instructions is appropriate?a) allow the client to go to the bathroomb) avoid creams and lotionsc) visitors are allowed to stay in the roomd) the client should remain in bed during the entire duration of treatment.

[Audio] Answer is D. the client should remain in bed during the entire duration of treatment.

[Audio] Rationale: the client receiving internal radiation therapy should be on complete bed rest to prevent dislodgement of the implant. The client has 2-way foley catheter during the treatment..

[Audio] 12. The client is receiving internal radiation therapy. The nurse shoulda) remember to give the badge to the next-shift nurseb) maintain a 30-minute close contact with the patient in a shiftc) wear gloves, mask and gown when entering the client's roomd) instruct relatives no to visit the client during the entire duration of the treatment.

[Audio] Answer is A. remember to give the badge to the next-shift nurse..

[Audio] Rationale: dosimeter badge is used to measure amount of exposure to radiation. It should be endorsed to the next shift.

[Audio] 13. A nurse is assessing a client with metastatic breast cancer who reports nocturia, weakness, nausea and vomiting. The client's serum electrolytes include potassium 4.2 mEq/L, sodium 135 mEq/L, calcium 7.0 mEq/L, and magnesium 2.0 mEq/L. Based on the assessment findings, the priority action for the nurse is to:a) start client on fluid restrictionb) administer calcium gluconatec) increase the client's IV fluidsd) administer Allopurinol.

[Audio] Answer is c. increase the client's IV fluids..

[Audio] Rationale: nocturia, nausea and vomiting cause dehydration. Therefore, the correct nursing action is to increase the client's IV fluids..

[Audio] 14. Which of the following nursing diagnoses would rank as the most important in the planning of care for a client in two weeks after the chemotherapy has begun?a) potential for infectionb) activity intolerancec) impaired skin integrityd) self-esteem disturbance.

[Audio] Answer is A. potential for infection. Graphical user interface, text, application Description automatically generated.

[Audio] Rationale: chemotherapy causes immunosuppression. Therefore, the patient is at risk to develop infection..

[Audio] 15. A client with acquired immunodeficiency syndrome ( AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client?a) consume foods and beverages that are high in glucoseb) plan large menus and cook meals in advancec) eat low-calorie snacks between mealsd) eat small, frequent meals throughout the day.

[Audio] Answer is D. eat small, frequent meals throughout the day.