Exam 2 Related Questions
A nurse provides home care instructions to a client with acute hepatitis. Which statement by the client indicates a need for further teaching? "I need to eat frequent small meals." "I need to eat foods high in carbohydrates and low in fat." "I need to maintain my normal physical activity and daily routine." "I need to avoid close physical contact with other people until my test results are negative."
"I need to maintain my normal physical activity and daily routine." RATIONALE: A client with hepatitis needs considerable rest during the acute phase of illness to promote healing of the liver. The permissible level of physical activity is based on the client's degree of fatigue and the severity of disease. Rest periods should be arranged throughout the day. The client should eat small frequent meals that are high in carbohydrate and low in fat. Close personal contact (e.g., kissing, sexual activity) should be discouraged until testing for hepatitis B surface antigen (HBsAg) returns a negative result.
The nurse is teaching a client about the late signs of testicular cancer. The nurse recognizes the client understands the teaching if the client selects which signs of late testicular cancer? Select all that apply. Bone pain Fluid in the scrotum Painless testicular swelling Presence of abdominal masses Dragging sensation in the scrotum
Bone pain Fluid in the scrotum Presence of abdominal masses RATIONALE: Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from nongerminal epithelium from other structures in the testicles. It may metastasize to the lung, liver, bone, and the adrenal glands. Early detection is made through routine testicular self-examination. The client may experience painless testicular swelling or a dragging sensation in the scrotum as early signs. Late signs, indicating metastasis, include testicular pain, back or bone pain, fluid in the scrotum, and respiratory symptoms; palpable lymphadenopathy, abdominal masses, and gynecomastia may also denote metastasis.
The nurse provides instructions to a client with type 1 diabetes mellitus with regard to foot care. The nurse determines there is a need for further teaching if the client makes which statement? I will inspect my feet daily. I will walk barefoot only at home. I will wash my feet with warm water and a mild soap. I will check my shoes for foreign objects before putting them on.
I will walk barefoot only at home.
A client with chronic kidney disease (CKD) has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which finding in the electrocardiographic (ECG) reading should the nurse expect to note? U waves Elevated P waves Tall, peaked T waves Shortened PR interval
Tall, peaked T waves RATIONALE: In CKD, hyperkalemia results from decreased renal excretion of potassium. The nurse should monitor the client's vital signs for hypertension or hypotension and the apical heart rate for irregularities. The nurse must also monitor the serum potassium level; a serum potassium level above 6 mEq/L can produce tall, peaked T waves; flat P waves; a widened QRS complex; and a prolonged PR interval on ECG in addition to decreased cardiac output; heart blocks, fibrillation, and asystole.
A client with a breast mass who is scheduled for an excisional breast biopsy asks the nurse about the procedure. What information should the nurse provide the client? The mass is removed entirely. Fluid is removed from the mass. Tissue is removed from the mass. Tissue is aspirated from the mass through a large-bore needle.
The mass is removed entirely. RATIONALE: In an excisional biopsy, the mass itself is removed for histologic (cellular) evaluation. An incisional biopsy involves the surgical removal of tissue from a mass. Aspiration biopsy is the removal of fluid or tissue from a mass through a large-bore needle.
The nurse assists a primary health care provider in performing a liver biopsy. In what position should the nurse place the client after the procedure? Prone Left Sims On the left side On the right side
on the right side RATIONALE: After a liver biopsy, the client is positioned on the right side for at least 2 hours to splint the puncture site and help prevent bleeding. Prone, left Sims, and left side-lying positions are all incorrect options.
The nurse provides information to the client about measures to treat gastroesophageal reflux disease (GERD). Which statement by the client indicates the need for further teaching? "I should stop drinking caffeinated coffee." "I should lie down for at least an hour after I eat." "I should prop up the head of my bed." "I shouldn't eat or drink anything for 2 hours before bedtime."
"I should lie down for at least an hour after I eat." RATIONALE: The client with GERD should avoid foods and positioning that decrease lower esophageal sphincter pressure or cause esophageal irritation. The client should consume a low-fat, high-fiber diet in small, frequent meals; minimize the amount of liquids drunk at mealtimes; and avoid reclining for 1 hour after eating; The client should also avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and elevate the head of the bed on 6- to 8-inch blocks.
A client with sepsis has been receiving intravenous antibiotics, and acute kidney injury has developed as a result. The nurse assesses the client and reviews the laboratory results. Which findings should the nurse expect to note during the oliguric stage of acute kidney injury? Select all that apply. A calcium level of 8.0 mg/dL (2 mmol/L) A creatinine level of 2.0 mg/dL (178.8 mcmol/L) A serum sodium level of 159 mEq/L (159 mmol/L) A serum potassium level of 3.1 mEq/L (3.1 mmol/L) A blood urea nitrogen level of 25 mg/dL (8.9 mmol/L)
A calcium level of 8.0 mg/dL (2 mmol/L) A creatinine level of 2.0 mg/dL (178.8 mcmol/L) A blood urea nitrogen level of 25 mg/dL (8.9 mmol/L) RATIONALE: In the oliguric stage of acute kidney injury, the GFR decreases. The client exhibits hyperkalemia, a normal or decreased sodium level (sodium retention occurs but is masked by the dilutional effects of water retention), hypocalcemia, and increased BUN and creatinine levels. During the diuretic stage, the GFR begins to increase and hypokalemia, hyponatremia, and hypovolemia develop, with gradual decreases in the levels of BUN and creatinine. The normal potassium level ranges from 3.5 to 5 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal BUN level ranges from 5 to 20 mg/dL, and the normal creatinine level ranges from 0.6 to 1.3 mg/dL. The normal calcium level ranges from 8.6 to 10 mg/dL.
The nurse is caring for a client who has had acute pancreatitis. Which change best indicates the client is recovering from pancreatitis? An increased amylase level A decrease in the lipase level Active bowel sounds in all four quadrants Abdominal pain that is relieved by lying down
A decrease in the lipase level RATIONALE: Pancreatitis is characterized by an increased amylase and lipase level, abdominal pain, even in the recumbent position. The bowel sounds can remain active. A decreased lipase level indicates the client is recovering.
A nurse is gathering subjective data from a client with suspected bladder cancer. Which early manifestation of bladder cancer the nurse would expect the client to report? Flank pain Groin discomfort Lower back pain Painless hematuria
Painless hematuria RATIONALE: Painless hematuria is the first sign of a bladder tumor in most clients. It may be gross or microscopic and is usually intermittent. Dysuria and urinary frequency or urgency are the usual symptoms when infection or obstruction is present. Flank pain indicates renal involvement. Lower back pain and groin discomfort may occur later in the course of the disease.
A nurse is reviewing the laboratory results of a client with Addison's disease. Which finding is most closely correlated with this disorder? Calcium level of 8.6 mg/dL (2.15 mmol/L) Sodium level of 145 mEq/L (145 mmol/L) Potassium level of 5.5 mEq/L (5.5 mmol/L) Blood glucose level of 110 mg/dL (6.1 mmol/L)
Potassium level of 5.5 mEq/L (5.5 mmol/L) RATIONALE: Laboratory testing in Addison's disease reveals hypoglycemia, hyperkalemia, hyponatremia, and hypercalcemia. The normal blood glucose level ranges from 70 to 110 mg/dL. The normal potassium level ranges from 3.5 to 5.0 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal calcium level ranges from 8.6 to 10 mg/dL.
Blood is drawn from a client with suspected hyperparathyroidism for a calcium assay, and a calcium level of 18 mg/dL (4.5 mmol/L) is detected. How should the nurse interpret this result? The calcium level is normal. The calcium level is low, indicating hyperparathyroidism. The calcium level is higher than normal, indicating hyperparathyroidism. The calcium level is on the low end of the normal range, indicating the need to increase dietary calcium.
The calcium level is higher than normal, indicating hyperparathyroidism. RATIONALE: Calcium functions in bone formation, nerve impulse transmission, and contraction of myocardial and skeletal muscles. It also aids in blood clotting by converting prothrombin to thrombin. The calcium concentration normally ranges from 8.6 to 10.0 mg/dL. Therefore, a calcium level of 18 mg/dL (4.5 mmol/L) is high, and the other options are incorrect.
A nurse is monitoring a client with hyperparathyroidism for signs of hypocalcemia and prepares to test the client for the Trousseau sign. Which item should the nurse obtain to perform this test? Cotton Tongue blade Reflex hammer Blood pressure cuff
BP cuff RATIONALE: The presence of the Trousseau sign is an indication of hypocalcemia. To test for the Trousseau sign, the nurse places a blood pressure cuff around the client's upper arm, inflates the cuff to a pressure greater than the client's systolic pressure, and keeps the cuff inflated for 1 to 4 minutes. In a positive result, the client's hands and fingers go into spasm in palmar flexion under these hypoxic conditions. Cotton, a tongue blade, and a reflex hammer are not needed to perform this test.
The nurse is providing pre-procedure instructions to a client who is scheduled for a endoscopic colonoscopy. Which teaching should be provided to the client? General anesthesia is required for the test to be performed. Hospitalization is required for 24 hours after the procedure. Complete bowel preparation is necessary before the procedure. Liquids and soft foods only are allowed on the morning before the test.
Complete bowel preparation is necessary before the procedure. RATIONALE: The client should consume a liquid diet for at least 24 hours before a colonoscopy and is usually on NPO status after midnight on the night before the procedure. Complete bowel preparation is necessary to enable the primary health care provider to visualize the entire colon. The primary health care provider prescribes medication that will help relax the client; general anesthesia is not necessary. The procedure is usually performed in an ambulatory care setting, and the client is discharged home after the procedure once his or her condition is stable.
A nurse is preparing a list of instructions regarding stoma and laryngectomy care to a client who has undergone laryngectomy. Which instructions should be included in the list? Select all that apply. Restrict fluid intake. Obtain a medical alert bracelet. Keep humidity in the home low. Avoid wearing high-collared clothing. Prevent debris from entering the stoma. Avoid swimming and use care when showering.
Obtain a medical alert bracelet. Prevent debris from entering the stoma. Avoid swimming and use care when showering. RATIONALE: The nurse should teach the client how to care for the stoma, tailoring the instructions to the type of laryngectomy that has been performed. Most interventions focus on protection of the stoma and the prevention of infection. The client is instructed to avoid swimming and to use care when showering, to avoid exposure to people with infections, to prevent debris from entering the stoma, and to obtain a medical alert bracelet. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing humidity in the home, and increasing fluid intake to 3000 mL/day to keep secretions thin.
A client hospitalized with prostate cancer is undergoing chemotherapy. While the nurse is helping the client with hygiene care, the client suddenly complains of severe back pain and numbness of the lower extremities. The nurse should take which immediate action? Contact the health care provider Administer pain medication Take the client's blood pressure Allow the client to rest and complete the bath later
Contact the health care provider RATIONALE: Spinal cord compression and damage occur when a tumor enters the spinal cord or when the vertebral column collapses as a result of tumor entry. A tumor may begin in the spinal cord or spread from another area of the body, such as the prostate gland, lung, breast, or colon. Spinal cord compression causes back pain, usually before neurological deficits occur. Such deficits include tingling; numbness; loss of urethral, vaginal, and rectal sensation; and muscle weakness. If paralysis occurs, it is usually permanent. The nurse would contact the health care provider to report the occurrence. Although pain medication may be needed, it is most appropriate to contact the health care provider so that a thorough evaluation of the client's pain may be conducted. Allowing the client to rest and completing the bath at a later time may be necessary, but this action delays necessary intervention. The nurse would expect the client's blood pressure to be increased if the client is in pain, and although the blood pressure would be measured, the most appropriate action is to contact the health care provider about the sudden occurrence of severe pain
A nurse is monitoring a client who has returned from colostomy surgery with an ostomy pouch system in place. On checking the stoma, the nurse notes that it is purple and firm. Which initial action by the nurse is appropriate? Documenting the findings Contacting the health care provider Placing warm packs over the stoma Changing the ostomy pouch system
Contacting the health care provider
A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which factors increase the risk for breast cancer and should be listed on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer Exposure of the chest to high-dose radiation Previous cancer of the breast, uterus, or ovaries
Early menarche Family history of breast cancer Exposure of the chest to high-dose radiation Previous cancer of the breast, uterus, or ovaries RATIONALE: Risk factors for breast cancer include family history; age; early or late menarche; late menopause; previous cancer of the breast, uterus, or ovaries; nulliparity or late first birth; exposure of the chest to high-dose radiation.
The school nurse receives a telephone call from a physical education teacher, who says that a student with diabetes mellitus is feeling shaky and weak. Which action should the nurse tell the teacher to take immediately? Laying the student on the floor Staying with the student until the nurse arrives Giving the student a glass of orange juice or non-diet soda Calling for an ambulance to bring the student to the emergency department
Giving the student a glass of orange juice or non-diet soda
The nurse is planning care for a client who has had a cholecystectomy with T-tube placement. Which nursing intervention should be emphasized as the priority in the plan of care? Provide a full liquid diet once clear liquids are tolerated. Help position the client into the semi-Fowler position. Administer pain and antiemetics as promptly as possible. Have the client turn, cough, and deep breathe every 2 hours.
Have the client turn, cough, and deep breathe every 2 hours. RATIONALE: It is most critical to prevent atelectasis following abdominal surgery, as the client may hypoventilate, due to the location of the incision. Providing full liquids is not as high a priority as preventing atelectasis. Positioning the client into the semi-Fowler position allows bile to drain into the bile bag, but preventing atelectasis is a higher priority. It is crucial to administer pain and antiemetics promptly, but preventing atelectasis is a higher priority.
Lydia has undergone the laparoscopic cholecystectomy and is in the immediate postoperative stage of recovery. During assessment, Lydia states that she is in pain, is cold, and feels sick to her stomach; she has diminished lung sounds and a small amount of bleeding from the incisional wound sites. Which actions by the nurse are appropriate? Select all that apply. Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths Removing the dressings to evaluate how much bleeding is occurring
Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths RATIONALE: The nausea that Lydia is experiencing could lead to vomiting. In the immediate postoperative stage of recovery, the gag reflex may not have returned. If Lydia vomits, she could aspirate the vomitus, which in turn could lead to pneumonia. Having Lydia lie on her left side will help prevent aspiration and help move the gas pocket of carbon dioxide that was used for the surgery away from the diaphragm. Covering Lydia with a blanket will help prevent the hypothermia that may occur during the postoperative period. Prescribed pain medication should be administered if Lydia is in pain and if the prescribed analgesic is due. The diminished lung sounds could lead to atelectasis if Lydia does not perform coughing and deep breathing or use her incentive spirometer. Bleeding may indicate a problem, but the amount of bleeding that would place the client at risk of hypovolemia or shock would be evident before the nurse removed the dressing.
A nurse provides instructions to a client with type 1 diabetes mellitus about home care measures to treat hypoglycemia. The nurse determines that the client understands the instructions if which statement is made? I will eat six saltine crackers I will call the health care provider I will report to the emergency department I will take an additional dose of regular insulin
I will eat six saltine crackers RATIONALE: Hypoglycemia is the term used to describe a blood glucose level below 70 mg/dL. If hypoglycemia is suspected, the client should obtain a glucose reading immediately. The client must consume a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (nondiet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. Administering regular insulin will lower the blood glucose. It is not necessary to notify the health care provider or to report to the emergency department for a single episode of hypoglycemia. The client should, however, contact the health care provider if hypoglycemia were to persist or hypoglycemic episodes were frequent.
A primary health care provider prescribes that the ammonia level be tested in a client with hepatic cirrhosis. The nurse transcribes the prescription and schedules the test for the next morning. Which appropriate action should the nurse take in preparation for the test? Requesting a liquid breakfast for the client on the morning of the test Imposing NPO status for the client starting 10 hours before the test Asking the dietary department to send an early breakfast to the client on the morning of the test Instructing the client to eat a high-fat snack at bedtime on the evening before the test and again on the morning of the test
Imposing NPO status for the client starting 10 hours before the test RATIONALE: The client must fast for 8 to 10 hours, except for water, and refrain from smoking for 8 to 10 hours before the test, because smoking increases the ammonia level. Ammonia, a byproduct of protein catabolism, is created mainly by bacteria acting on proteins present in the gut. Ammonia is metabolized by the liver and excreted by the kidneys as urea. An increased level resulting from hepatic dysfunction may lead to encephalopathy. In the incorrect options, the client is being allowed to consume fluids other than water and to eat.
The nurse is changing the ties on a client's tracheostomy. During the procedure, the client coughs and the tracheostomy tube is dislodged. Which immediate action should the nurse take? Calling respiratory therapy to replace the tube Covering the stoma with a sterile dressing and ventilating the client manually with a resuscitation bag Placing the client in the high Fowler position and encouraging the client to breathe deeply through the stoma until help arrives Inserting the obturator into the replacement tracheostomy tube, lubricating the tip with saline solution, and inserting the tube into the stoma
Inserting the obturator into the replacement tracheostomy tube, lubricating the tip with saline solution, and inserting the tube into the stoma RATIONALE: If a tracheostomy tube is accidentally dislodged, the nurse's immediate action is to try to replace it. If retention sutures are present, they are grasped and the opening spread. A hemostat can also be used to spread the opening to facilitate replacement of the tube. The obturator is inserted in the replacement tube and lubricated with saline solution poured over the tip, after which the tube is inserted in the stoma at a 45-degree angle to the neck. If the nurse is unsuccessful in replacing the tube, the client is ventilated with a resuscitation bag until help arrives. Minor dyspnea may be relieved with the use of the semi-Fowler position until help arrives. The nurse may need to call respiratory therapy for assistance, but the immediate action is replacement of the tube.
A nurse checks the laboratory test results of a client who is undergoing chemotherapy and notes that the client's platelet count is 90,000 cells/mm. In light of this result, which action by the nurse is appropriate? Instituting bleeding precautions Instituting neutropenic precautions Informing the client that the test result is normal Educating the client about the importance of increasing iron in the diet
Instituting bleeding precautions RATIONALE: The appropriate action by the nurse would be to institute bleeding precautions for the client. Platelets are produced by the bone marrow to function in hemostasis. The normal platelet count ranges from 150,000 to 400,000 cells/mm. A decrease in the number of platelets puts the client at risk for bleeding. Neutropenic precautions are instituted when the WBC count is low because the client is at risk for infection. Increasing dietary iron would not help increase platelet formation.
The nurse is providing home care information to a client who has undergone a skin biopsy. Which information should the nurse include in the instructions? Soak the site in warm water three times a day Expect redness and drainage at the biopsy site Expect a significant amount of pain at the biopsy site Keep the dressing dry and in place for at least 8 hours
Keep the dressing dry and in place for at least 8 hours RATIONALE: After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for at least 8 hours. After the dressing is removed, the site is cleansed daily with tap water or saline solution to remove dried blood or crusts. The primary health care provider may also prescribe a topical antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report the presence of redness or excessive drainage at the biopsy site. Pain should be minimal after a skin biopsy.
A nurse provides information to a client who has undergone a Billroth II procedure about dietary measures to prevent dumping syndrome. Which menu choices by the client indicates an understanding of the teaching? Select all that apply. Milk Rice Eggs Beef Apple pie
Rice Eggs Beef RATIONALE: Dumping syndrome, a complication of gastric resection, is the rapid emptying of gastric contents into the small intestine. To prevent or minimize dumping syndrome, the client is instructed to eat a high-protein, high-fat, low-carbohydrate diet; to eat small, frequent meals; to avoid drinking fluids with meals; avoid milk, sweets, and other foods containing sugars; and to lie down after meals. Rice, eggs, and beef are all acceptable foods.
Following a kidney, ureters, and bladder (KUB) x-ray, the client has been diagnosed with urolithiasis. The nurse provides home care instructions to the client and provides the client with which instruction(s)? Select all that apply. Strain all urine for stones. Drink plenty of fluids daily. Avoid walking or other activity. Apply ice to the area where the pain is located. Restrict food intake until the stone has passed.
Strain all urine for stones. Drink plenty of fluids daily. RATIONALE: Urolithiasis refers to the formation of urinary stones or calculi, which are usually formed in the ureter. Home care measures are directed toward promoting passage of the stone. The client is encouraged to ingest daily fluids as prescribed by the primary health care provider to facilitate passage of the stone and prevent infection. All urine is strained for stones, which are sent to the laboratory for analysis as prescribed to assist in determining treatment. The client is instructed to take warm baths and apply heat to the area of discomfort; cold may cause spasms and will increase the discomfort. Ambulation is encouraged; this will assist in the passage of the stone. There is no useful reason to restrict food.
A nurse is reading the medical record of a client admitted to the hospital with a diagnosis of diabetes insipidus. Which of these signs/symptoms should the nurse expect to see documented in the client's record? Select all that apply. Anuria Tachycardia Complaints of thirst Moist mucous membranes Complaints of muscle weakness Blood pressure of 168/98 mm Hg
Tachycardia Complaints of thirst Complaints of muscle weakness RATIONALE: Diabetes insipidus is a disorder of water metabolism caused by hyposecretion of ADH and a deficiency of vasopressin. Signs/symptoms include polyuria (5 to 20 L/day), polydipsia, signs of dehydration, inability to concentrate urine and a low urinary specific gravity of 1.006 or less, fatigue, muscle pain and weakness, postural hypotension and tachycardia.
A client is being assessed for the presence of postural (orthostatic) hypotension. Which procedure should the nurse perform to assess the client for this condition? Taking the client's pulse while the client is standing, asking the client to lie down and retaking the pulse in 30 minutes, and finally, comparing the findings Taking the client's pulse while the client is lying down, asking the client to sit in a chair and retaking the pulse in 3 minutes, and, finally, comparing the findings Taking the client's blood pressure while the client is lying down, asking the client to sit in a chair and retaking the blood pressure in 1 to 3 minutes, asking the client to stand for 1 to 3 minutes and retaking the blood pressure a third time, and, finally comparing the findings Taking the client's blood pressure while the client is standing, asking the client to sit in a chair for 1 to 3 minutes and retaking the blood pressure, asking the client to lie down for 1 to 3 minutes and retaking the blood pressure a third time, and, finally, comparing the findings
Taking the client's blood pressure while the client is lying down, asking the client to sit in a chair and retaking the blood pressure in 1 to 3 minutes, asking the client to stand for 1 to 3 minutes and retaking the blood pressure a third time, and, finally comparing the findings RATIONALE: Postural (orthostatic) hypotension is the presence of signs/symptoms of low blood pressure on rising to an upright position in a normotensive individual. The blood pressure is checked with the client supine, sitting, and standing. The readings are obtained 1 to 3 minutes after the client changes position. When documenting orthostatic blood pressure measurements, the nurse records the client's position in addition to the client's blood pressure.
The nurse should include which information in the preoperative plan of care for a client with appendicitis? Select all that apply. Administer a Fleet enema Allow sips of clear fluids only Apply an ice bag to the abdomen Administer 15 mL milk of magnesia orally Insert an intravenous (IV) line and infuse IV fluids as prescribed
apply an ice bag to the abdomen insert and IV line and IV fluids as prescribed RATIONALE: A concern for the client with appendicitis is rupture and resultant peritonitis. Surgery, generally performed laparoscopically, is performed as soon as the diagnosis is made. To ensure that the stomach is empty in the event that surgery is needed, the client is kept on nothing-by-mouth (NPO) status. Antibiotics and fluid resuscitation are administered before surgery. Laxatives and enemas are especially dangerous because the resulting increased peristalsis may cause perforation of the appendix. An ice bag may be applied to the right lower quadrant to decrease inflammation. Heat can cause the appendix to rupture.
Rosanne is being started on intravenous trastuzumab, an antineoplastic medication. Which assessment finding indicates an adverse effect of the medication? Nausea Headache Tiredness Irregular heartbeat
irregular heartbeat RATIONALE: Cardiomyopathy and ventricular dysfunction are adverse effects of trastuzumab. A baseline electrocardiogram (ECG) will be done. Signs of toxicity will show on the concurrent ECG and may be noted by an irregular heartbeat. Nausea, headache, and loss of strength and energy are side effects of the medication.
