The nurse is assessing a client's B - Tumor lysis syndrome (TLS) results in hyperkalemia, hypocalcemia,
laboratory values following hyperuricemia, and hyperphosphatemia. A serum calcium level of 5,
administration of chemotherapy. which is low, is an indicator of possible tumor lysis syndrome.
Which lab value leads the nurse to
suspect that the client is
experiencing tumor lysis syndrome
(TLS)?
a. Serum PTT of 10 seconds.
b. Serum calcium of 5 mg/dL.
c. Oxygen saturation of 90%.
d. Hemoglobin of 10 g/dL
Which description of symptoms is B - Trigeminal neuralgia is characterized by paroxysms of pain, similar to
characteristic of a client diagnosed an electric shock, in the area innervated by one or more branches of
with trigeminal neuralgia (tic the trigeminal nerve (5th cranial). Women are more often afflicted with
douloureux)? this condition and generally occurs in clients over the age of 50 years
a. Tinnitus, vertigo, and hearing old.
difficulties.
b. Sudden, stabbing, severe pain
over the lip and chin.
c. Facial weakness and paralysis.
d. Difficulty in chewing, talking, and
swallowing.
,Which discharge instruction is most C - After a renal transplantation, acute rejection is a high risk for several
important for a client after a kidney months. The organ recipient will have to take immunosuppressive
transplant? therapy for the rest of their lives, such as corticosteroids and
a. Weigh weekly. azathioprine, to prevent organ transplant rejection. Discharge
b. Report symptoms of secondary instructions include measures such as daily reminders to ensure the
Candidiasis. client takes these medications regularly to prevent organ rejection from
c. Use daily reminders to take occurring.
immunosuppressants.
d. Stop cigarette smoking.
The nurse is providing dietary B - To reduce risk factors associated with coronary heart disease, the
instructions to a 68-year-old client daily intake of soluble fiber should be increased to between 10 and 25
who is at high risk for development grams per day. According to the American Heart Association, soluble
of coronary heart disease (CHD). fibers helps reduce LDL cholesterol levels.
Which information should the nurse
include?
a. Limit dietary selection of
cholesterol to 300 mg per day.
b. Increase intake of soluble fiber to
10 to 25 grams per day.
c. Decrease plant stanols and
sterols to less than 2 grams/day.
d. Ensure saturated fat is less than
30% of total caloric intake.
,Two days postoperative, a male D - For a client exhibiting symptoms of deep vein thrombosis (DVT), a
client reports aching pain in his left complication of immobility, the initial care includes bedrest and
leg. The nurse assesses redness and elevation of the extremity.
warmth on the lower left calf. Which
intervention would be most helpful
to this client?
a. Apply sequential compression
devices (SCDs) bilaterally.
b. Assess for a positive Homan's sign
in each leg.
c. Pad all bony prominences on the
affected leg.
d. Advise the client to remain in bed
with the leg elevated.
, A middle-aged male client with A - The loss of a limb due to diabetes by a family member should be the
diabetes continues to eat an strongest event or "cue to action" and is most likely to increase the
abundance of foods that are high in client's perceived seriousness of the disease.
sugar and fat. According to the
Health Belief Model, which event is
most likely to increase the client's
willingness to become compliant
with the prescribed diet?
a. He visits his diabetic brother who
just had surgery to amputate an
infected foot.
b. He is provided with the most
current information about the
dangers of untreated diabetes.
c. He comments on the community
service announcements about
preventing complications
associated with diabetes.
d. His wife expresses a sincere
willingness to prepare meals that
are within his prescribed diet.
laboratory values following hyperuricemia, and hyperphosphatemia. A serum calcium level of 5,
administration of chemotherapy. which is low, is an indicator of possible tumor lysis syndrome.
Which lab value leads the nurse to
suspect that the client is
experiencing tumor lysis syndrome
(TLS)?
a. Serum PTT of 10 seconds.
b. Serum calcium of 5 mg/dL.
c. Oxygen saturation of 90%.
d. Hemoglobin of 10 g/dL
Which description of symptoms is B - Trigeminal neuralgia is characterized by paroxysms of pain, similar to
characteristic of a client diagnosed an electric shock, in the area innervated by one or more branches of
with trigeminal neuralgia (tic the trigeminal nerve (5th cranial). Women are more often afflicted with
douloureux)? this condition and generally occurs in clients over the age of 50 years
a. Tinnitus, vertigo, and hearing old.
difficulties.
b. Sudden, stabbing, severe pain
over the lip and chin.
c. Facial weakness and paralysis.
d. Difficulty in chewing, talking, and
swallowing.
,Which discharge instruction is most C - After a renal transplantation, acute rejection is a high risk for several
important for a client after a kidney months. The organ recipient will have to take immunosuppressive
transplant? therapy for the rest of their lives, such as corticosteroids and
a. Weigh weekly. azathioprine, to prevent organ transplant rejection. Discharge
b. Report symptoms of secondary instructions include measures such as daily reminders to ensure the
Candidiasis. client takes these medications regularly to prevent organ rejection from
c. Use daily reminders to take occurring.
immunosuppressants.
d. Stop cigarette smoking.
The nurse is providing dietary B - To reduce risk factors associated with coronary heart disease, the
instructions to a 68-year-old client daily intake of soluble fiber should be increased to between 10 and 25
who is at high risk for development grams per day. According to the American Heart Association, soluble
of coronary heart disease (CHD). fibers helps reduce LDL cholesterol levels.
Which information should the nurse
include?
a. Limit dietary selection of
cholesterol to 300 mg per day.
b. Increase intake of soluble fiber to
10 to 25 grams per day.
c. Decrease plant stanols and
sterols to less than 2 grams/day.
d. Ensure saturated fat is less than
30% of total caloric intake.
,Two days postoperative, a male D - For a client exhibiting symptoms of deep vein thrombosis (DVT), a
client reports aching pain in his left complication of immobility, the initial care includes bedrest and
leg. The nurse assesses redness and elevation of the extremity.
warmth on the lower left calf. Which
intervention would be most helpful
to this client?
a. Apply sequential compression
devices (SCDs) bilaterally.
b. Assess for a positive Homan's sign
in each leg.
c. Pad all bony prominences on the
affected leg.
d. Advise the client to remain in bed
with the leg elevated.
, A middle-aged male client with A - The loss of a limb due to diabetes by a family member should be the
diabetes continues to eat an strongest event or "cue to action" and is most likely to increase the
abundance of foods that are high in client's perceived seriousness of the disease.
sugar and fat. According to the
Health Belief Model, which event is
most likely to increase the client's
willingness to become compliant
with the prescribed diet?
a. He visits his diabetic brother who
just had surgery to amputate an
infected foot.
b. He is provided with the most
current information about the
dangers of untreated diabetes.
c. He comments on the community
service announcements about
preventing complications
associated with diabetes.
d. His wife expresses a sincere
willingness to prepare meals that
are within his prescribed diet.
