intake of sodium, protein, potassium, and fluidsmay lead to a dangerous accumulation of electrolytes and protein metabolic products,such as amino acids and ammonia. Therefore,the client must limit his intake of sodium, meat(high in Protein), bananas (high in potassium),and fluid because the kidneys can’t secreteadequate urine.20. The nurse is caring for a client who has justhad a modified radical mastectomy withimmediate reconstruction. She’s in her 30s andhas tow children. Although she’s worried abouther future, she seems to be adjusting well to herdiagnosis. What should the nurse do to supporther coping?A. Tell the client’s spouse or partner to besupportive while she recovers.B. Encourage the client to proceed with the nextphase of treatment.C. Recommend that the client remain cheerfulfor the sake of her children.D. Refer the client to the American CancerSociety’s Reach for Recovery program oranother support program.ANS: D The client isn’t withdrawn or showing other signsof anxiety or depression. Therefore, the nursecan probably safely approach her about talkingwith others who have had similar experiences,either through Reach for Recovery or anotherformal support group. The nurse may educatethe client’s spouse or partner to listen toconcerns, but the nurse shouldn’t tell the client’sspouse what to do. The client must consult withher physician and make her own decisionsabout further treatment. The client needs toexpress her sadness, frustration, and fear. Shecan’t be expected to be cheerful at all times.21. A 21 year-old male has been seen in theclinic for a thickening in his right testicle. Thephysician ordered a human chorionicgonadotropin (HCG) level. The nurse’sexplanation to the client should include the factthat:A. The test will evaluate prostatic function.B. The test was ordered to identify the site of apossible infection.C. The test was ordered because clients whohave testicular cancer has elevated levels of HCG.D. The test was ordered to evaluate thetestosterone level.ANS: CHCG is one of the tumor markers for testicularcancer. The HCG level won’t identify the site of an infection or evaluate prostatic function ortestosterone level.22. A client is receiving captopril (Capoten) forheart failure. The nurse should notify thephysician that the medication therapy isineffective if an assessment reveals:A. A skin rash.B. Peripheral edema.C. A dry cough.D. Postural hypotension.ANS: BPeripheral edema is a sign of fluid volumeoverload and worsening heart failure. A skinrash, dry cough, and postural hypotension areadverse reactions to captopril, but the don’tindicate that therapy isn’t effective.23. Which assessment finding indicatesdehydration?A. Tenting of chest skin when pinched.B. Rapid filling of hand veins.C. A pulse that isn’t easily obliterated.D. Neck vein distentionANS: A Tenting of chest skin when pinched indicatesdecreased skin elasticity due to dehydration.Hand veins fill slowly with dehydration, notrapidly. A pulse that isn’t easily obliterated andneck vein distention indicate fluid overload, notdehydration.24. The nurse is teaching a client with a historyof atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage theclient to:A. Avoid focusing on his weight.B. Increase his activity level.C. Follow a regular diet.D. Continue leading a high-stress lifestyle.ANS: B The client should be encouraged to increase hisactivity level. Maintaining an ideal weight;following a low-cholesterol, low-sodium diet; andavoiding stress are all important factors indecreasing the risk of atherosclerosis.25. For a client newly diagnosed withradiationinducedthrombocytopenia, the nurse shouldinclude which intervention in the plan of care?A. Administer aspirin if the temperature exceeds38.8º C.B. Inspect the skin for petechiae once everyshift.C. Provide for frequent periods of rest.D. Place the client in strict isolation.ANS: BBecause thrombocytopenia impairs bloodclotting, the nurse should assess the clientregularly for signs of bleeding, such aspetechiae, purpura, epistaxis, and bleedinggums. The nurse should avoid administeringaspirin because it can increase the risk of bleeding. Frequent rest periods are indicated forclients with anemia, not thrombocytopenia. Strictisolation is indicated only for clients who havehighly contagious or virulent infections that arespread by air or physical contact.26. A client is chronically short of breath and yethas normal lung ventilation, clear lungs, and anarterial oxygen saturation (SaO2) 96% or better. The client most likely has:A. poor peripheral perfusionB. a possible Hematologic problemC. a psychosomatic disorderD. left-sided heart failureANS: BSaO2 is the degree to which hemoglobin issaturated with oxygen. It doesn’t indicate theclient’s overall Hgb adequacy. Thus, anindividual with a subnormal Hgb level could havenormal SaO2 and still be short of breath. In thiscase, the nurse could assume that the client hasa Hematologic problem. Poor peripheralperfusion would cause subnormal SaO2. Thereisn’t enough data to assume that the client’sproblem is psychosomatic. If the problem wereleft-sided heart failure, the client would exhibitpulmonary crackles.27. For a client in addisonian crisis, it would bevery risky for a nurse to administer:A. potassium chlorideB. normal saline solutionC. hydrocortisoneD. fludrocortisoneANS: AAddisonian crisis results in Hyperkalemia;therefore, administering potassium chloride iscontraindicated. Because the client will behyponatremic, normal saline solution isindicated. Hydrocortisone and fludrocortisoneare both useful in replacing deficient adrenalcortex hormones.28. The nurse is reviewing the laboratory reportof a client who underwent a bone marrowbiopsy. The finding that would most stronglysupport a diagnosis of acute leukemia is theexistence of a large number of immature:A. lymphocytesB. thrombocytesC. reticulocytesD. leukocytesANS: DLeukemia is manifested by an abnormaloverpopulation of immature leukocytes in thebone marrow.29. The nurse is performing wound care on afoot ulcer in a client with type 1 diabetesmellitus. Which technique demonstrates surgicalasepsis?A. Putting on sterile gloves then opening acontainer of sterile saline.B. Cleaning the wound with a circular motion,moving from outer circles toward the center.