Units 8-18

Which individual is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure?

"The uterus weighs about 2 ounces."

After a liver biopsy, the nurse should place the client in which position?

A right side-lying position with a small pillow or folded towel under the puncture site

The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube?

3.5

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

36%

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply.

50 mL of drainage in the drainage-collection chamber The drainage system is maintained below the client's chest. An occlusive dressing is in place over the chest-tube insertion site. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?

9 months

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data?

A superficial injury to tissue from the radiation

An older client recently has been taking cimetidine (Tagamet). The nurse should monitor the client for which most frequent central nervous system side effect of this medication?

Confusion

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube?

Enables the client to speak

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

A client has been prescribed amikacin (Amikin). Which priority baseline function should be monitored?

Hearing acuity

A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed?

High-fiber diet

The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client?

High-sodium, high-carbohydrate diet

The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?

Leakage of clear fluid from the nose

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage?

Neurological deficits

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process?

Perform Valsalva's maneuver.

The nurse prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client with chronic kidney disease for which laboratory abnormality?

Potassium level of 7.2 mEq/L

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

Protruding and swollen

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which?

Punch biopsy of the cutaneous lesions

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection?

Red, shiny skin around the nail bed

The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

Reduction of steatorrhea

The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed?

Semi-Fowler's position

Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

Signs of hepatitis Flu-like syndrome Low neutrophil count Ocular pain or blurred vision