Extract:

Question 1 of 5

A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:

Correct Answer: B

Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.

Question 2 of 5

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often. B. I can place an aspirin tablet in my pouch to decrease odor. C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it. D. I must use a skin barrier to protect my skin from urine. E. I should supply my ostomy pouch of urine when it is full.

Correct Answer: C,D

Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.

Question 3 of 5

A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?

A. Initiate an intake and output record. B. Place the client on bed rest. C. Place the client on contact isolation. D. Keep the client out of sunlight.

Correct Answer: B

Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.

Question 4 of 5

A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?

A. Reverse Trendelenburg. B. Low Fowler’s. C. High lithotomy. D. Prone.

Correct Answer: C

Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.

Question 5 of 5

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:

A. Altered balance. B. Altered protective pressure sensation. C. Impaired hearing ability. D. Impaired visual acuity.

Correct Answer: B

Rationale: Older adults have reduced pressure sensation due to thinner skin and nerve changes, increasing the risk of skin breakdown and pressure ulcers.