MS Ch 16 17 18

The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students that the average daily fluid intake for an adult is?

2500 mL

The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?

3:1

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?

Tumor pressure against normal tissues

The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?

Flush the toilet twice after every use.

A client who is being treated for bladder cancer expresses his concern of passing cancer to his wife during intercourse. Which is the best response by the nurse?

"Cancer is not transferred from person to person via direct contact."

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?

"In my experience, clients who know are more likely to be involved with their plan of care."

The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?

"My cancer has now spread to my liver."

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?

"The client is in shock because the blood volume has decreased in the system."

A client with a 4-cm breast mass is scheduled for biopsy with frozen section followed by lumpectomy and possible mastectomy. The client asks the nurse, "Why can't the doctor tell me specifically whether I will need to have my entire breast removed"? Which is the best response from the nurse?

"The frozen section will determine presence of cancer and type of surgery required."

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?

"Tumor removal will promote comfort."

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

What is one process by which dissolved chemicals move from one area of the body to another?

Active transport

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.

You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?

Avoid spicy and fatty foods

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

Dark, concentrated urine

A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation

Which of the following can be considered carcinogens?

Dietary substances

What lab result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?

Extravasation

You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

Kidney stones and blood clots.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?

Malignant tumor

The nurse working on a bone marrow unit knows that is is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?

Monitor the client closely to prevent infection.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

Multiple organ failure

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted

The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of 40 mL from the Foley catheter, which nursing action is most appropriate?

Record 40 mL as the hourly output.

You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should you do?

Seek a physician's order to dilute the infusion

The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?

Sun safety and use of sunscreen

A newly diagnosed cancer client is crying and states the following to the nurse: "I promised God that I will be a better person if I can just get better." What is the appropriate assessment of this comment by the nurse?

The cancer is viewed as a punishment for past actions.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the followin

The difference between the systolic and the diastolic pressure.

The nurse is caring for the client with massive blood loss from a gunshot wound. With little time to spare, which blood type is infused?

Type O

The physician recommends that you have your daughter vaccinated with HPV vaccine. What is this vaccine for?

Help prevent cervical cancer.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

You are an oncology nurse caring for a client who is taking antineoplastic agents. What adverse symptoms must you monitor for in this client?

Symptoms of gout