Extract:

Question 1 of 5

A 17-year-old client has been admitted to the hospital for a biopsy to confirm the diagnosis of bone cancer. The nurse should assess the client for which conditions? Select all that apply.

Correct Answer: C,D,E,F,G

Rationale: Bone cancer may cause pain, swelling, fever, anorexia, and decreased range of motion due to tumor effects on bone and surrounding tissues. Cough and dyspnea are less common unless metastasis occurs.

Question 2 of 5

The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.

A. Maintain the client in a position of comfort. B. Collect sputum specimens at the hour of sleep. C. Offer medication to suppress the cough as needed. D. Administer small, frequent meals with plenty of fluids. E. Have the client cough and breathe deeply 20 minutes after pain medication is given. F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.

Correct Answer: A,D,E

Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.

Question 3 of 5

What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm?

A. An adverse event B. A root cause C. A healthcare acquired event D. A sentinel event

Correct Answer: A

Rationale: An adverse event is a healthcare-related incident that may have led to client harm, such as medication errors or falls.

Question 4 of 5

Which neurological complication can occur when a vest restraint is too tight around the client's body?

A. Strangulation B. Skin breakdown C. Skin pallor D. Numbness

Correct Answer: A

Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.

Question 5 of 5

Select the complication of intravenous therapy that is accurately paired with one of its interventions.

A. Infection: Lowering the limb to promote circulation B. Infiltration: The application of cold to the site C. Extravasation: The aspiration of contents including blood from the IV cannula D. Hematoma: The administration of dexrazoxane

Correct Answer: C

Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.