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Question 1 of 5

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

Correct Answer: A, C, D

Rationale: Short fingernails (
A), cholestyramine timing (
C), and moisturizing cream (
D) reduce itching and protect skin. Hot water (
B) worsens itching, and wool gloves/tight stockings (E) may irritate skin.

Question 2 of 5

The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?

Correct Answer: A

Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.

Question 3 of 5

The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?

Correct Answer: C

Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.

Question 4 of 5

Diagnosis-related groups (DRGs) provide data to

Correct Answer: C

Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.

Question 5 of 5

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.

Correct Answer: A, B, D

Rationale: Avoiding rubbing (
A), straining (
B), and reporting sudden pain (
D) prevent complications. Flashes (
C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.

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