Nursing Fund- raquel_yniguez/ Study sets for exam 4

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results Rationale: Blood lab results provide objective data about fluid and electrolyte status as well as about hemoglobin and hematocrit. Intake and output results provide data only about fluid balance but doesn't present a comprehensive picture of the client's fluid and electrolyte status and therefore is not the best answer. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. The client's report about fluid intake is a subjective data in general and not reliable because this client has dementia and therefore has memory problems.

A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred Vision Rationale: Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups (singultus) are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the drug, an improved cardiac output.

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?

"My incision will probably be painful" The TURP procedure is performed by insertion of a scope device into the urethra to reachthe prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.

A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?

28 mL Rationale: At 15 lb the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The other amounts (32 mL, 38 mL, 42 mL) are too much.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous solution will be prescribed initially?

0.9% sodium chloride Rationale: An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client, because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. 3% sodium chloride, is a high concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. 5% dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be appropriate fluids to infuse after 0.9% sodium chloride.

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

1. Check health care provider's prescription 2. Obtain vital signs and history of transfusions 3. Ascertain that intravenous catheter size is 18 or 20 gauge 4. Change main line solution to normal saline 5. Check client identification before hanging unit of blood Rationale: Check the health care provider's prescription to notify blood bank what product will be needed. Obtain the client's baseline vital signs and ask if the client has had previous transfusions and if there were any untoward effects. Ascertaining the intravenous catheter size is at least an 18 will prevent hemolysis of red blood cells. The main line solution must be normal saline 0.9 to flush the line and use as a main line if the blood administration must occur because of a reaction. Other solutions can affect blood, causing it to clot. Checking the client identification and verification of blood product is necessary before proceeding.

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. (Record your answer using a whole number.)

31 Rationale: Administering 1,000 mL over 8 hours is equal to administering 125 mL over 1 hour (60 minutes). To find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 mL/minute To find the number of drops/minute: 2.1 mL/X gtts = 1 mL/15 gtts X = 31 gtts/minute

A client who has been diagnosed with acute lymphocytic leukemia will be receiving doxorubicin (Adriamycin) infusions as part of a chemotherapy regimen. The nurse monitors the client for signs and symptoms of doxorubicin toxicity. What clinical finding indicates that toxicity has occurred?

Abnormalities in cardiac rhythm Rationale: Doxorubicin is cardiotoxic, which is manifested by transient ECG abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect. Dyspnea and a metallic taste to food are not effects of doxorubicin.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?

Cervical Rationale: Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows after the disease progresses.

A child with acute lymphoid leukemia is started on a chemotherapy protocol that includes prednisone. What side effect of this medication does the nurse anticipate?

Mood Changes Rationale: Euphoria and mood swings may result from steroid therapy. Alopecia does not result from steroid therapy. An increased appetite, not anorexia, results from steroid therapy. Weight gain, not weight loss, results from steroid therapy.

A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What signs and symptoms does the nurse expect when obtaining the health history and performing a physical assessment? Select all that apply

Anorexia, Petechiae Rationale: Anorexia occurs as a result of catabolism. Platelet count is decreased because of bone marrow depression resulting in bleeding tendencies; petechiae and ecchymoses result. Edema is not expected with ALL. Alopecia is not related to the disease process; it occurs as a result of chemotherapy. The red blood cell count is decreased because of bone marrow depression; the child will be lethargic and sleep excessively.

A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother tells the nurse that her child is asking for fried chicken. How should the nurse respond?

Any food that is requested should be given, because the child needs calories. Rationale: Because chemotherapy can cause nausea, vomiting, and anorexia, the child should be offered any food that is requested. Even if the nutritional quality is minimal, the child will be receiving needed calories. Fried foods can usually be eaten because generally they do not cause nausea and vomiting or irritate the mouth. Food prepared adequately should not be contaminated and therefore should not cause problems for a child undergoing chemotherapy.

A client is receiving whole-body radiation for Hodgkin disease. Which side effect should the nurse expect as a result of this therapy?

Decreased number of erythrocytes Rationale: Depression of the bone marrow interferes with hemopoiesis, resulting in anemia. A decrease in the number of cells occurs, and therefore there is an increase in blood viscosity and a more rapid clotting time. Pathologic fractures result from the disease, not from the treatment. Radiation causes increased susceptibility to infection as a result of the decreased number of white blood cells.

A 28-year-old male client is undergoing tests to confirm the diagnosis of Hodgkin lymphoma. The client and his wife are worried that he may have cancer. The wife states, "Don't you think it is unlikely for someone like my husband to have cancer?" The nurse's response is based on the information that Hodgkin lymphoma is:

Diagnosed during adolescence and young adulthood Rationale: Hodgkin lymphoma occurs most often during the ages of 15 to 35 years of age and between 50 to 60 years of age. Hodgkin lymphoma affects younger men and women equally and affects more men than women between the ages of 50 and 60 years. The incidence of Hodgkin lymphoma is not limited to people in older age groups. The prevalence of Hodgkin lymphoma is increased in teenagers and young adults (15 to 35 years of age). Asian populations are less likely to develop Hodgkin lymphoma than other populations.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what are the symptoms of bleeding for which they should be looking in the future. What are the signs for which to look? Select all that apply.

Epistaxis, Hematuria, Hemarthrosis, Easy bruising, Dark colored tarry stools Epistaxis, also known as nosebleeds, is a common symptom of a lack of clotting factor. Hematuria (blood in the urine) may be grossly apparent. The child may experience joint pain and deformities from bleeding into joints. Excessive bruising will occur from bleeding into tissue with seemingly minor injuries. Dark colored tarry consistency stools are indicative of gastrointestinal bleeding. Frequent fevers are not associated with hemophilia. Prolonged clotting times occur with this condition.

A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17 mEq/L. What complication does the nurse conclude has developed?

Metabolic acidosis Rationale: The blood pH indicates acidosis; the bicarbonate (HCO3-) level is further from the expected range than is the partial pressure of carbon dioxide (Pco2), indicating a metabolic origin (losses from diarrhea). The blood pH indicates acidosis, not alkalosis. The HCO3- level is farther from the expected range than the Pco2 level, indicating a metabolic, not a respiratory, origin of the acidosis. The blood pH indicates an acidic, not an alkalotic, state; also, it is of metabolic origin.

A client is receiving ABVD (doxorubicin [Adriamycin], bleomycin [Blenoxane], vinblastine [Velban], and dacarbazine [DTIC]) therapy for Hodgkin disease. About halfway through the first six-month course of treatment, the client complains of burning and tingling of the feet. The nurse determines that these symptoms are a result of:

Neurotoxicity caused by vinblastine Rationale: Neurotoxicity is a common and expected side effect of vinblastine. Dacarbazine is not known to cause neurotoxicity. Hypersensitivity reactions include rashes and photosensitivity. Although doxorubicin causes myelosuppression, myelosuppression does not cause symptoms of neurotoxicity. Burning and tingling are not associated with vasoconstriction but rather to neurotoxicity. Bleomycin is not known to cause neurotoxicity.

A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant's hydration status?

Obtaining daily weights Daily weighing provides an objective measurement because a weight loss indicates a loss of fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an objective measure, it is necessary to weigh the diapers before and after the infant voids to estimate the amount of fluid loss. Intake can be measured accurately; however, output, especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open to a variety of interpretations. Also, the site that should be assessed is over the sternum, not the abdomen.

A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client?

Provide frequent saline mouthwashes. Rationale: Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral mucosa

The treatment regimen for a female diagnosed with Hodgkin disease, stage III, will start with nodal irradiation. Because the client and her husband have been trying to conceive a child, the client becomes visibly anxious when she learns that the radiation therapy includes the pelvic nodal area. When questioned about this, the nurse should refer the client to the primary health care provider because:

Reproductive ability may be preserved through a variety of interventions Rationale: Reproductive ability may be preserved through shielding the ovaries or harvesting ova. Radiation can influence or destroy ovarian functioning. Sterilization can occur. Women in the childbearing years should be informed of all options available to preserve ovarian function. Once ova are destroyed, they cannot regenerate.

After an infant undergoes surgery for the repair of a myelomeningocele, diarrhea and metabolic acidosis, accompanied by decreased urine output, develop. In light of the infant's status, what prescription does the nurse anticipate?

Sodium Lactate Rationale: Sodium lactate is converted to sodium bicarbonate; it helps correct the sodium deficiency and the metabolic acidosis. Normal saline solution results in the combination of the chloride with the hydrogen ion, intensifying the acidosis. Albumin is a colloid found in blood plasma; it is not used in the treatment of metabolic acidosis. Potassium is not administered until urine function has been restored.

A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy?

Sore in the mouth Rationale: Stomatitis is a common response to chemotherapy and should be brought to the health care provider's attention because a swish-and-swallow anesthetic solution can be prescribed to make the client more comfortable. Although a low-grade fever may occur, it does not require immediate medical attention. Moderate diarrhea is expected and is not a cause for concern unless dehydration results. Nausea is expected but should be reported if it lasts more than 24 hours.

A young female client who lives with her parents is diagnosed with stage III Hodgkin disease with a grossly involved spleen and is scheduled for a splenectomy. After the nurse performs preoperative teaching, the client appears anxious. What is the best approach for the nurse to use at this time?

State that she seems anxious and ask her whether she would like to talk for a while Rationale: Stating that she seems anxious and asking her whether she would like to talk for a while provides an opportunity for the client to explore concerns with the nurse. The data do not indicate regression; the client is anxious, not regressed. The nurse is basing the response on an incorrect interpretation of the data. The data do not indicate that the client does not understand; the nurse should attempt to provide for consensual validation before coming to this conclusion.

Three months after beginning chemotherapy, a client develops severe anorexia, stomatitis, and episodes of diarrhea. The nursing plan includes increasing fluid and caloric intake and measures to relieve discomfort caused by stomatitis. To address the plan, the nurse should recommend that the client:

Suck on an ice pop every two hours Rationale: Ice pops provide calories and fluid, and the cold relieves discomfort associated with the stomatitis. Water does not provide calories, only fluid. Tea has no calories, and warm drinks will increase, not decrease, the discomfort associated with the stomatitis. Although rinsing the mouth with nystatin after meals may prevent infection, it does not provide calories or fluid, or relieve discomfort associated with the stomatitis

A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment?

Tender mass in the left upper abdomen Rationale: Splenomegaly usually accompanies chronic myelogenous leukemia; the spleen usually is gross, palpable, and tender and necessitates removal. The spleen is located high in the abdomen on the left side and usually is not palpable unless it is enlarged. The urinary output is not affected with these conditions. With leukemia and splenomegaly there is increased destruction of blood cells; the erythrocyte count will be low. Polydipsia, increased appetite, and urinary frequency are not associated with leukemia or splenomegaly, but rather diabetes.