3
13.
A client has alopecia as a result of chemotherapy and is concerned as to the extent of her hair loss. Whichexplanation by the nurse would be most appropriate?a.
Explain how dose and type of medication administered will be the determining factor for hair regrowth.b.
Reassure client that hair will look as good as before treatment, maybe even better.c.
Describe how hair will not grow back unless special measures are used during chemotherapy.d.
Explain how the color and texture of the new hair maybe different, but the hair loss is usually notpermanent.
Reassuring the client that hair will grow back after the completion of chemotherapy is important. Some clients willbegin to have hair growth before the course of chemotherapy is finished. Option #1 is secondary to Option #4.Options #2 and #3 are incorrect
.
14.
Which nursing observations would relate to the complication of intestinal obstruction following an exploratorylaparotomy?a.
Protruding soft abdomen with frequent diarrhea.b.
Distended abdomen with ascites.c.
Minimal bowel sounds in all four quadrants.d.
Distended abdomen with complaints of pain.
If an obstruction is present, the abdomen will become distended and painful. Options #1and #2 do not supportintestinal obstruction. Option #3 is incorrect because immediately postoperative abdominal surgery, a clients bowelsounds are absent or decreased.
15.
A client with prostatic cancer is admitted to the hospital with neutropenia. Which signs and symptoms are mostimportant for the nurse to report to the next shift?a.
Arthralgia and stiffness.b.
Vertigo and headache.c.
General malaise and anxiety.d.
Temperature elevation and lethargy.
With a low WBC (neutropenia), the client is at risk for the development of infection. Options #1 and #2 could beexperienced but are rot most important. Option #3 is more closely associated with anemia.
16.
A client with chronic cancer pain has been receiving Demerol 100 mg PO q4h PRN for pain, without much relief.Which change in narcotic pain management would be the most valid suggestion to make to the physician?a.
Decrease to twice a day.b.
Decrease to every 6 hours PRN.c.
Give every 4 hours around the clock.d.
Give every 2 hours PRN.
Research shows that around-the-clock (ATC) administration of analgesics is more effective in maintaining bloodlevels to alleviate the pain associated with cancer. Options #1 and #2 actually decrease the amount of painmedication. Option #4 might be too frequent an interval.
17.
Which priority is first when inserting an indwelling urinary catheter?a.
Aseptic technique.b.
Taping the catheter to the leg.c.
Instilling water into the balloon.d.
Inserting the catheter to the point where the urine flows.
Prevention of infection is apriority. When ever a foreign tube is being introduced into the body, there is always achance for infection to occur. Option #2 is incorrect. Option #3 is incorrect because it should be sterile water andeven then is not a priority. Option #4 contains incorrect information as the catheter is usually inserted 2-3 inchesbeyond the flow of urine
.
18.
Based on the assessment findings of oliguria, hyperkalemia, and increased BUN on a client
in
chronic renalfailure, an appropriate nursing diagnosis would be:a.
fluid volume excess and electrolyte imbalanceb.
related to decreased urinary outputc.
altered nutrition less than body requirements related to anorexia and dietary restrictions.d.
knowledge deficit regarding condition and treatment regimen.
In renal failure, oliguria is accompanied by an increased BUN, increased serum potassium, and decreased renalblood flow. Option #2 is incorrect because it addresses other information not in the question. Option #3 does nothave related to as part of the diagnosis. Option #4 is incorrect because oliguria is decreased urinary output, notincreased urinary output.
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