900

The nurse is assessing a client with thigh high antiembolism stockings. Assessment findings include redness, swelling, and pain in the left calf. What is the priority action by the nurse?

Notify the healthcare provider.

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence?

"How safe do you feel in your home?"

A client with posttraumatic stress disorder states, "You don't know what I've been through. What can you do?" The nurse should respond:

"I haven't been through what you have, but I'll be better able to understand if you tell me more about it."

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client:

"It's frightening to have new people on the unit. We're here to talk about things like being afraid."

Which client statement indicates an understanding of the risk of alcohol relapse?

"Stopping support groups and not expressing feelings can lead to relapse."

The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate?

"Tell me what you've found in your reading that's leading you to that conclusion."

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is notproducing sufficient amounts of a factor that allows the vitamin to be absorbed."

During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?

"This test will screen for spina bifida, Down syndrome, or other genetic defects."

A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse's best response?

"Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs."

The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia?

A client with digoxin toxicity

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providingthis information is an example of which of the following?

A referral.

A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of A) Acute tuberculosis with a productive cough of discolored sputum for over three months B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen C) Pseudomembranous colitis and C. difficile. D) Exacerbation of polyarthritis with severe pain

A) Acute tuberculosis with a productive cough of discolored sputum for over three months

The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability

A) Decrease in level of consciousness

The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? A) Inspect the skin B) Auscultate breath sounds C) Evaluate muscle strength D) Investigate elimination patterns

A) Inspect the skin

Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes

A) Oral ingestion

The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? A) Pulse oximetry of 85% B) Nocturia C) Crackles in lungs D) Diaphoresis

A) Pulse oximetry of 85%

The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan to A) Restrict visitors to immediate family B) Avoid arousal of the client except for family visits C) Keep client's hips flexed at no less than 90 degrees D) Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

A) Restrict visitors to immediate family

A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate

A) Should be taken in the morning

An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by A) Tachypnea B) Acidic byproducts C) Vomiting and dehydration D) Hyperpyrexia

A) Tachypnea

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check

A) go get a blood pressure check within the next 48 to 72 hours

A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client's behavior is a warning sign to indicate that the client may be A) headed for relapse B) feeling hopeless C) approaching recovery D) in need of increased socialization

A) headed for relapse

The LPN/LVN is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption."

A. "Hold the medication in your mouth for a few minutes before swallowing it."

The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A. A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago

A. A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? A. Administer another nitroglycerin tablet. B. Apply 1 to 3 L/minute of oxygen via nasal cannula. C. Call for a 12-lead electrocardiogram (ECG) to be performed. D. Wait an additional 5 minutes, then give a second nitroglycerin tablet.

A. Administer another nitroglycerin tablet.

A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would best prevent further regression in the client's personal hygiene? A. Encouraging the client to perform as much self-care as possible B. Making the client assume responsibility for physical care C. Assigning a staff member to take over the client's physical care D. Accepting the client's desire to go without bathing

A. Encouraging the client to perform as much self-care as possible

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? A. Flat B. Semi-Fowler's C. Trendelenburg's D. Reverse Trendelenburg's

A. Flat

A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience: A. hypotension. B. hypertension. C. seizures. D. renal toxicity.

A. Hypotension.

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. A. Nicotine decreases oxygen to the heart. B. Hypnosis may be helpful to stop smoking. C. Avoid exposure to environmental tobacco smoke. D. Cigars or pipes are healthier than cigarette smoking. E. Tobacco smoking increases a female's level of estrogen.

A. Nicotine decreases oxygen to the heart. B. Hypnosis may be helpful to stop smoking. C. Avoid exposure to environmental tobacco smoke.

Following a client's bladder surgery, the practical nurse (PN) notes that the ureteral catheter is no longer draining urine. What action should the PN implement? A. Notify the healthcare provider immediately. B. Change the client's position and continue to monitor. C. Clamp the ureteral catheter for 30 minutes. D. Irrigate the ureteral catheter with 30 ml of sterile saline.

A. Notify the healthcare provider immediately.

The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. A. Obtain annual influenza vaccination. B. Restrict fluid intake to 1000 mL per day. C. Avoid adding salt to foods or in cooking. D. Report a weight gain of 3 or more pounds in a week. E. Take an extra dose of prescribed diuretic for swollen ankles.

A. Obtain annual influenza vaccination. C. Avoid adding salt to foods or in cooking. D. Report a weight gain of 3 or more pounds in a week.

Which action should the practical nurse implement when changing bed linens of a client with radioactive implant? A. Stay at the bedside under the prescribed time exposure. B. Use a N95 respirator mask with a special filter. C. Wear a paper gown and boots, gloves, and mask. D. Extend time after linen change to alleviate client's anxiety.

A. Stay at the bedside under the prescribed time exposure.

The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? A. The client requires prophylactic antibiotics before treatment. B. The dentist should use a low-speed drill to avoid dysrhythmias. C. The dentist should use a lidocaine solution without epinephrine. D. The client is at risk for episodes of heart failure triggered by stressful events.

A. The client requires prophylactic antibiotics before treatment.

The practical nurse (PN) is administering an otic medication to an adult client. In which direction should the PN pull the pinna during instillation? A. Up and back. B. Down and back. C. Up and forward. D. Down and forward.

A. Up and back.

The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? A. Weigh self every morning before breakfast. B. Sleep with the head elevated on only one pillow. C. Adjust diuretic dose based on severity of peripheral edema. D. Take additional digoxin (Lanoxin) if respiratory distress occurs.

A. Weigh self every morning before breakfast.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: A. fold towels and pillowcases. B. play cards with another client. C. participate in a game of charades. D. perform an aerobic exercise.

A. fold towels and pillowcases.

In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by: A. hypothyroidism B. hyperglycemia C. hypertension D. anti-seizure medication

A. hypothyroidism

A client, age 20, is being treated for depression. During a conversation with the nurse, she states that her father raped her when she was 7 years old. She says she has nightmares about the experience and sometimes relives it. She also reveals that she fears older men. The client may be exhibiting signs of: A. post traumatic stress disorder (PTSD), delayed onset. B. multiple personality disorder. C. anxiety disorder. D. schizophrenia.

A. post traumatic stress disorder (PTSD), delayed onset.

A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify dose.

A.Administer the prescribed dose at the scheduled time.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A.Place the client on NPO status. B.Assess the client's temperature. C.Obtain a stool specimen. D.Administer IV fluids.

A.Place the client on NPO status.

Which mediation can the nurse administer through a nasogastric (NG) tube?

Acetaminophen

A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate:

Aggression

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priority intervention?

Ask for additional information from the client.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

A client with an uncomplicated term pregnancy arrives at the laborand-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?

Ask what time this happened and note the color, amount, and odor of the fluid.

What is the priority nursing intervention in the postictal phase of a seizure?

Assess the client's breathing pattern.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse's immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today."

B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."

The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk."

B) "When you can climb 2 flights of stairs without problems, it is generally safe."

When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by A) Reduced oxygen capacity of cells due to lack of iron B) An imbalance between red cell destruction and production C) Depression of red and white cells and platelets D) Inability of sickle shaped cells to regenerate

B) An imbalance between red cell destruction and production

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach? A) Consider a liquid supplement to increase calories B) Discuss consequences of an unbalanced diet with the child C) Provide fruit, vegetable and protein snacks D) Encourage the child to keep a daily log of foods eaten

B) Discuss consequences of an unbalanced diet with the child

A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive

B) Lead to dehydration

A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function

B) Left heart function

As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid A) Surfing B) Scuba diving C) Parasailing D) Swimming

B) Scuba diving

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse

B) Send him to the emergency room for evaluation

The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints

B) Spinal column manipulation

A male client draws back when the practical nurse (PN) reaches over the side rails to take his blood pressure. To promote effective communication, what should the PN do? A. Continue to perform the procedure quickly and quietly. B. Apologize for startling the client and explain the need for contact. C. Tell the client that the blood pressure can be taken at a later time. D. Rotate the nurses who are assigned to take the client's blood pressure.

B. Apologize for startling the client and explain the need for contact.

A male client is being discharged after starting a new prescription of olanzapine (Zyprexa) for paranoid schizophrenia. Which discharge instructions should the practical nurse (PN) reinforce with the client? A. Sit in the sunlight for 20 minutes everyday. B. Avoid the use of antihistamines and alcohol. C. Maintain an average dietary intake of sodium. D. Defer making business decisions for a month.

B. Avoid the use of antihistamines and alcohol.

A client with a massive cerebral bleed who is diagnosed as brain dead is receiving mechanical ventilation. The healthcare provider has just talked to the family about removing the client from life support. Which family concern should the practical nurse (PN) relay to the charge nurse immediately? A. Family request for an autopsy. B. Client's designation for organ donation. C. Referral to the coroner's office. D. Notification of the insurance company.

B. Client's designation for organ donation.

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? A. Dark, pink base B. Deep and painful C. Accompanied by very slight pain D. Brown pigmentation of surrounding skin

B. Deep and painful

A client visits the clinic with complaints of sleep loss and wants a prescription for sleeping pills. The practical nurse (PN) learns that the client is also drinking tea at the evening meals. What action should the PN implement? A. Talk to the client about history of changes in sleeping habits. B. Determine if the tea is caffeinated or has an herbal supplement in it. C. Instruct the client on the appropriate dose for the sleeping pills. D. Have a translator interpret all instructions about the sleeping pills.

B. Determine if the tea is caffeinated or has an herbal supplement in it.

The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. A. Defibrillation B. Digoxin (Lanoxin) C. Warfarin (Coumadin) D. Electrical cardioversion E. Amiodarone (Cordarone)

B. Digoxin (Lanoxin) C. Warfarin (Coumadin) D. Electrical cardioversion

The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? A. Shaves the front of the client's chest B. Gives the client a device holder to wear around the waist C. Teaches the client to rest as much as possible during the next 24 hours D. Tells the client to cover the monitor in plastic wrap before taking a bath

B. Gives the client a device holder to wear around the waist

To help prevent complications for a client who is abusing amphetamines, it is important for the practical nurse to implement what action? A. Measure intake and output. B. Perform neurologic assessments. C. Check oxygen levels frequently. D. Keep the lights on continuously.

B. Perform neurologic assessments.

The healthcare provider prescribes wrist restraints for an older male resident in a long term care facility who is confused and has pulled out his urinary catheter twice. The practical nurse (PN) assesses the client's radial pulses and skin condition under the restraint every 2 hours. Which additional measures should the PN implement? Select all that apply. A. Verify that restraints are prescribed on an as-needed basis. B. Remove the restraints daily to reevaluate the client's needs. C. Ask the client for his consent to be restrained for his safety. D. Discontinue the restraints when the client is no longer at risk for self injury. E. When the time frame of the prescription has lapsed, discontinue the restraints.

B. Remove the restraints daily to reevaluate the client's needs. D. Discontinue the restraints when the client is no longer at risk for self injury.

Which finding requires immediate action by the practical nurse (PN)? A. The client's affected heel is supported off of the bed. B. The weights are touching the floor at the end of the bed. C. The affected leg and foot are resting away from the footboard. D. The client's affected leg is aligned parallel to the edge of the bed.

B. The weights are touching the floor at the end of the bed.

A male client with acute pancreatitis has a nasogastric tube (NGT) to suction. He asks the practical nurse (PN) if he can have some sips of water or ice chips. Which rationale should the PN explain to the client about remaining NPO? A. To prevent nausea and vomiting. B. To minimize pancreatic secretions that cause pain. C. To remove any precipitating irritants from the stomach. D. To correct fluid and electrolyte imbalance.

B. To minimize pancreatic secretions that cause pain.

When using nonsterile procedure gloves, which action should the practical nurse (PN) implement to ensure standard precautions are provided to all clients? A. Use gloves for any contact with the client. B. Wash hands immediately after removing the gloves. C. Wash hands with gloves on before removing them. D. Use the same gloves throughout the care of the same client.

B. Wash hands immediately after removing the gloves.

One aspect of implementation related to drug therapy is: A. developing a content outline. B. documenting drugs given. C. establishing outcome criteria. D. setting realistic client goals.

B. documenting drugs given.

The nurse is teaching a client about malabsorption syndrome and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the: A. stomach. B. small intestine. C. large intestine. D. rectum.

B. small intestine.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A.Stress incontinence B.Infection C.Painless gross hematuria D.Peritonitis

B.Infection

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client INDICATES UNDERSTANDING of the teaching? (Select all that apply.) A.White bread B.Salmon C.Broccoli D.Whole milk E.Banana

B.Salmon C.Broccoli E.Banana

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A.Reducing dairy products in the diet B.Straining all urine C.Measuring intake and output D.Increasing fluid intake

B.Straining all urine

A client has been prescribed corticosteroids. The nurse would also anticipate an order for

Blood glucose checks every 6 hours.

A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend."

C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."

A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asked to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse demonstrating emotional support for the client? A) "No, it would be best if you brought the client some reading material that she could read at night." B) "No, your presence may cause the client to become more anxious." C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D) "Yes, would you like to spend the night when the client's behavior indicates that she is frightened?"

C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."

When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day

C) Avoiding very heavy meals

In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss

C) Bed wetting

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy

C) Confine the percussion to the rib cage area

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia

C) Distended neck veins

The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score? A) Birth weight B) Racial differences C) Fetal distress in labor D) Birth trauma

C) Fetal distress in labor

The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be A) High calorie, low fat, low sodium B) High protein, low fat, low carbohydrate C) High protein, high calorie, unrestricted fat D) High carbohydrate, low protein, moderate fat

C) High protein, high calorie, unrestricted fat

While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying

C) Inspiratory grunt

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection

C) Manage pain

A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? A) Moist mucous membranes B) Urinary frequency C) Poor skin turgor D) Increased blood pressure

C) Poor skin turgor

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A) Anxiety, unconscious anger, and hostility B) Guilt, indecisiveness, poor self-concept C) Psychomotor retardation or agitation D) Meticulous attention to grooming and hygiene

C) Psychomotor retardation or agitation

Which action is most likely to ensure the safety of the nurse while making a home visit? A) Observation during the visit of no evidence of weapons in the home B) Prior to the visit, review client's record for any previous entries about violence C) Remain alert at all times and leave if cues suggest the home is not safe D) Carry a cell phone, pager and/or hand held alarm for emergencies

C) Remain alert at all times and leave if cues suggest the home is not safe

Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

C) The level of drug is 100 ml at 8 AM and is 80 ml at noon

An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10

What method should the practical nurse (PN) implement to elicit information from a client during an admission interview? A. Explain the purpose of the admission interview. B. Summarize with the client the information collected. C. Ask information-seeking or closed-ended questions. D. Request relatives to leave during the interview.

C. Ask information-seeking or closed-ended questions.

A 9-year-old boy who had an emergency appendectomy during the night awakens and starts to cry when he does not see his parents at the bedside. He has an IV and a dressing covering the operative site. What action should the practical nurse (PN) implement? A. Encourage the child to calm down because big boys do not cry. B. Locate his mother and ask her to stay at the bedside with her son. C. Ask the child to recall the surgical event and assess his pain level. D. Call the healthcare provider for a prescription for a different analgesic.

C. Ask the child to recall the surgical event and assess his pain level.

A male client in a skilled nursing home has metastatic cancer and has requested comfort care only. During the day, he does not want to get out of bed because he is too tired and weak to sit in a chair. He sleeps on and off all day and night, his position is changed every 2 hours, and he is comfortable on his pain control regimen. Which action should the practical nurse (PN) implement at the beginning of the next day shift? A. Encourage client to continue activities of daily hygiene to stay active and awake. B. Assist him to sit in a chair for an hour each day and perform passive exercises. C. Assess his desire to get out of bed or remain in bed in a position of comfort. D. Awaken client during day for short time interval to facilitate nighttime sleep.

C. Assess his desire to get out of bed or remain in bed in a position of comfort.

The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Which instruction should the nurse include when teaching the adolescent about ferrous sulfate? Select all that apply: A. Take the supplement with food. B. Report black stools to the physician immediately. C. Avoid taking the supplement with milk. D. Avoid taking the supplement with antacids. E. Avoid chewing the extended-release form of the drug.

C. Avoid taking the supplement with milk. D. Avoid taking the supplement with antacids. E. Avoid chewing the extended-release form of the drug.

The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? A. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet B. Pork chop, baked potato, cauliflower in cheese sauce, ice cream C. Baked haddock, steamed broccoli, herbed rice, sliced strawberries D. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

C. Baked haddock, steamed broccoli, herbed rice, sliced strawberries

The practical nurse (PN) is caring for a client following aortic aneurysm resection with graft placement. Which laboratory finding should the PN report to the charge nurse immediately? A. Hematocrit 36%, hemoglobin 12 grams/dl. B. Sodium 145 mEq/L, potassium 4.0 mEq/L. C. Blood urea nitrogen 25 mg/dl, creatinine 2.0 mg/dl. D. Partial thromboplastin time 30 seconds, prothrombin time 12 seconds.

C. Blood urea nitrogen 25 mg/dl, creatinine 2.0 mg/dl.

A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: A. use an electric breast pump. B. apply warm, moist compresses to the breasts. C. breast-feed every 1 1⁄2 to 3 hours. D. wear a brassiere 24 hours per day.

C. Breast-feed every 1 1⁄2 to 3 hours.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.

C. Change the bag when the seal is broken.

A client who is ready for transport from the postanesthesia care unit (PACU) to the postoperative unit continues to complain of pain at the incision site. What action should the practical nurse (PN) implement? A. Administer a dose of analgesic as written in the client's postoperative prescriptions. B. Give a half-dose of the prescribed postoperative dosage of analgesic medication. C. Consult with the anesthesia healthcare provider for a prescribed dose of analgesia. D. Tell the client that pain medication cannot be given until transfer to the postoperative unit.

C. Consult with the anesthesia healthcare provider for a prescribed dose of analgesia.

Which action should the practical nurse (PN) implement to improve delivery of care by an unlicensed assistive personnel (UAP) who is providing less than optimal hygienic care to older adult clients? A. Give the UAP verbal instructions on how to correctly give baths. B. Ask another staff member to provide special skin care in the afternoon. C. Demonstrate to the UAP how to give a gentle bath to a client. D. Provide the UAP with reading and resources on bathing older clients.

C. Demonstrate to the UAP how to give a gentle bath to a client.

A client with delirium is confused and disoriented to time and place. He states he is experiencing visual illusions and tactile hallucinations. What actions in the plan of care should the practical nurse (PN) implement? Select all that apply. A. Interact in an energetic manner to dismiss misperceptions. B. Provide a wide variety of environmental stimuli. C. Give simple explanations about nursing care to be given. D. Remove unnecessary furniture and equipment from the room. E. Encourage self care to promote client independence. F. Identify oneself each time the client is approached.

C. Give simple explanations about nursing care to be given. D. Remove unnecessary furniture and equipment from the room. F. Identify oneself each time the client is approached.

In addition to lowering dietary sodium intake, which dietary changes should the practical nurse (PN) encourage the client to make when learning to manage high blood pressure? A. Vary the types of dairy products, such and milk and cheese. B. Select vegetable proteins, such as canned beans. C. Include calcium and magnesium food sources daily. D. Increase protein source of shellfish to most days of the week.

C. Include calcium and magnesium food sources daily.

The practical nurse is discussing glucose balance with a client who is newly diagnosed with type 2 diabetes mellitus. Which physiological process supports the movement of glucose into the cells? A. Glucose moves to low concentrations in the cell. B. Blood pressure pushes glucose into cells. C. Insulin is needed to carry glucose into cells. D. Cells absorb glucose when needed.

C. Insulin is needed to carry glucose into cells.

Which action should the practical nurse (PN) implement to facilitate an effective airway clearance for a client who has a stridor and is coughing while experiencing an allergic reaction? A. Turn the client to a side-lying position. B. Offer the client a glass of water to drink. C. Place the client in a high Fowler's position. D. Percuss the client's back during coughing.

C. Place the client in a high Fowler's position.

A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? A. Restating B. Reframing C. Reflecting D. Offering a general lead

C. Reflecting

Which acid-base imbalance is a client with a history of severe chronic obstructive pulmonary disease (COPD) likely to develop? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

C. Respiratory acidosis.

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A. Fluid volume deficit B. Self-care deficit C. Risk for infection D. Impaired nutrition

C. Risk for infection

Damage to which area of the brain results in receptive aphasia? A. Parietal lobe B. Occipital lobe C. Temporal lobe D. Frontal lobe

C. Temporal lobe

A mother who is a single parent of three children comes into the well-child clinic and tells the nurse that she needs to start prenatal visits because she unexpectantly is pregnant. To determine how well the client is coping with the pregnancy, which information should the practical nurse obtain? A. The type of work the client is currently doing for employment. B. The client's plans for marriage in the near future. C. The client's support person during this pregnancy. D. The client's use of any type of contraception.

C. The client's support person during this pregnancy.

Which task should the practical nurse (PN) assign to an unlicensed assistive personnel (UAP)? A. Check medical record for new prescriptions. B. Change dressings for a client with an infected wound. C. Toilet a client on a bladder-training regimen. D. Evaluate blood pressure for a client who has fallen.

C. Toilet a client on a bladder-training regimen.

In the prescribed clinical pathway for an elderly client who is bedridden after the repair of a broken hip, transfer to the rehabilitation unit should be implemented at 1 week postoperatively. Which intervention is most important for the practical nurse (PN) to direct the unlicensed assistive personnel (UAP) to implement to ensure the client can progress to this expected outcome? A. Encourage isotonic and active bed exercises for progressive mobilization plan. B. Provide meals and snacks high in protein to prevent muscle loss and weakness. C. Turn, cough, and deep-breathe q2 hoursto prevent secretion pooling in lungs. D. Offer fluids and urinal q2 hours to maintain hydration and bladder function.

C. Turn, cough, and deep-breathe q2 hoursto prevent secretion pooling in lungs.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution.

C.Notify the health care provider of the findings immediately.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

Chicken and orange slices

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?

Collaborate with the interprofessional team to make a referral to social services.

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should

Collect the specimen in a sterile container.

The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: "We are concerned about the possible occurrence of sudden infant death syndrome (SIDS)." In order to take appropriate action, the nurse must understand that A) The child is within the age group most susceptible to SIDS B) The peak age for occurrence of SIDS is 8 to 12 months of age C) The apnea monitor is not effective on a child in this age group D) 95% of SIDS cases occur before 6 months of age

D) 95% of SIDS cases occur before 6 months of age

A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? A) Riding in a car B) Falling off a bed C) Electrical outlets D) Eating peanuts

D) Eating peanuts

A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder

D) Have the client empty bladder

The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? A) Hypertonic neuro reflex B) Immediate CNS depression C) Lethargy and sleepiness D) Jitteriness at 24-48 hours

D) Jitteriness at 24-48 hours

Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure

D) Note patterns of increased blood pressure

A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status

D) Notify the healthcare provider of the child's status

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? A) Reading B) Checkers C) Cards D) Ping-pong

D) Ping-pong

What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year

D) Yearly weight gain of about 5.5 pounds per year

Which interventions are appropriate when caring for a client with acute thrombophlebitis? A. Apply cool soaks and keep the client's leg lower than the level of the heart. B. Increase the client's activity level and encourage leg exercises. C. Apply cool soaks and administer nitroglycerin. D. Apply warm soaks and elevate the client's legs higher than the level of the heart.

D. Apply warm soaks and elevate the client's legs higher than the level of the heart.

An older client who is a resident in a skilled nursing facility likes to walk for exercise. The client is taking a vasodilator for hypertension. Which action should the practical nurse (PN) implement for this client? A. Monitor blood pressure daily. B. Provide a walker for long walks. C. Document intake and output. D. Assist client to stand up slowly.

D. Assist client to stand up slowly.

A client has collapsed while getting out of bed, has no pulse, and is not breathing. After calling for help and an automated external defibrillator (AED), which action should the practical nurse (PN) take? A. Give two quick short breaths. B. Palpate for a carotid pulse. C. Defibrillate using the AED. D. Begin cardiac compressions.

D. Begin cardiac compressions.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? A. Blood pressure B. Respirations C. Temperature D. Cardiac rhythm

D. Cardiac rhythm

The practical nurse (PN) assigns the unlicensed assistive personnel (UAP) to take the vital signs for a client with bacterial meningitis. Which finding should the PN direct the UAP to report immediately? A. Subnormal temperatures. B. Muscle flaccidity. C. Low blood pressure. D. Changes in consciousness.

D. Changes in consciousness.

The practical nurse (PN) palpates the insertion site of an IV infusion that is pale and swollen, and determines the area is cool to touch. Which action should the PN implement first? A. Report to the nurse. B. Apply warm compresses to the site. C. Monitor client's temperature q4 hours. D. Discontinue the IV infusion.

D. Discontinue the IV infusion.

A male client who was hospitalized for depression 1 month ago is being discharged. The client asks a female practical nurse (PN) for a date when he gets home. How should the PN respond? A. Decline and state that another person is significant to the PN. B. Explain hospital policy that does not allow nurses to date clients. C. Accept the invitation but clarify that their meeting should be platonic relationship. D. Explain the nurse-client relationship is a professional relationship, not a social one.

D. Explain the nurse-client relationship is a professional relationship, not a social one.

The practical nurse (PN) is examining a newborn and identifies that the gluteal skin folds of the buttocks are uneven and one of the thighs is shorter than the other. Which assessment should the PN implement next? A. Visualize the anal and urinary meatus openings. B. Manipulate both ankles for range of motion. C. Count the number of fingers and toes. D. Flex and abduct hips simultaneously

D. Flex and abduct hips simultaneously

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

D. Infection

A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation.

D. Reassign the PN until the resident can be assessed more completely for reality orientation.

A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale

D. Regular insulin subcutaneously per sliding scale

In which position should the practical nurse (PN) place a client after the client has a liver biopsy? A. Prone. B. Supine. C. Left side-lying. D. Right-side lying.

D. Right-side lying.

Which client outcome should the practical nurse (PN) identify for a client with heart failure (HF)? A. The client's weight fluctuates by less than 2 kg per day. B. The client requests medication for anxiety only at night. C. The heart rate increases by 50 beats per minute with mild exercise. D. The client is able to dress and feed self without experiencing dyspnea.

D. The client is able to dress and feed self without experiencing dyspnea.

The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B.Exhibit regular, soft-formed stool within 1 month. C.Demonstrate the irrigation procedure correctly within 1 week. D.Attend an ostomy support group within 2 weeks.

D.Attend an ostomy support group within 2 weeks.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have onthe client's functioning in the hospital?

Decrease the client's feelings of isolation and loneliness.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician.

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:

Discuss the situation and possible courses of action with the dietitian and the client.

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next?

Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan?

Has a known history of sexually transmitted disease.

A nurse is preparing to administer an I.V. containing dextrose 10% in 1⁄4 normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

Institute droplet precautions.

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should thenurse take? Select all that apply.

Label the vial with the strength of the medication. Store the multi-dose vial in a secure place. Initial the vial as the person reconstituting the medication.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

Limiting abbreviations to those approved for use by the institution

For a client with Graves' disease, which nursing intervention promotes comfort?

Maintaining room temperature in the low-normal range

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

Massages the client's legs.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines.

A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving I.V. push morphine for painmanagement. During rounds, the nurse discusses with the physician the need to start the client on a continuous morphine infusion. The nurse bases this request on the fact that:

Serving as a client advocate is an important role

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should?

Take measures to ensure privacy during the counselor's visit.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?

The client admitted after a head injury in a motor vehicle who reports nausea

Which of the following clients should the nurse assess first?

The client who is a child with stridor and nasal flaring

A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine 75 mg three times a day and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client?

The depression is improving, and the suicidal ideation is Lessening

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

To clear secretions from the tubing

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer?

Transfer board

A client with diabetes is taking insulin lispro injections. At what time should the nurse advise the client to eat?

Within 10 to 15 minutes after the injection.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

cough and shortness of breath