A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports:
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Solution
Answer A is correct. Many clients with Hodgkin’s lymphoma report finding enlarged nodes in the neck when shaving. Answer B is associated with brain tumors; therefore, it is incorrect. Answer C is associated with leukemia; therefore, it is incorrect. Answer D is associated with renal cancer; therefore, it is incorrect.
Which breakfast selection is suitable for the client on a high-fiber diet?
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Solution
Answer B is correct. Oatmeal and grapefruit wedges are high in fiber. Answers A, C, and D are incorrect because they contain less fiber
The nurse is assessing a client immediately following delivery. The nurse notes that the client’s fundus is boggy. The nurse’s next action should be to:
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Solution
Answer C is correct. Gently massaging the fundus immediately following delivery will help it to contract. Answer A is incorrect because the uterus would be displaced to one side if the bladder was distended. Answer B is incorrect. The nurse should first massage the fundus before notifying the doctor. Answer D is incorrect because uterine relaxation is not associated with pain.
The physician has ordered Cephulac (lactulose) for a client with increased serum ammonia. The nurse knows the medication is having its desired effect if the client experiences:
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Solution
Answer B is correct. Lactulose is given to produce diarrhea, which lowers the client’s serum ammonia levels. Answers A, C, and D are not associated with the use of lactulose; therefore, they are incorrect.
The nurse is assisting the physician with the insertion of an esophageal tamponade. Before insertion, the nurse should:
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Solution
Answer A is correct. Unless the manufacturer recommends otherwise, the nurse should inflate and deflate the gastric and esophageal balloons to make sure they are not defective. Answer B refers to the insertion of a standard nasogastric tube; therefore, it is incorrect. Answer C is incorrect because the esophageal tamponade is usually removed after 48 hours. Answer D is incorrect because the esophageal tamponade has a port for gastric suction.
The nurse is instructing a post-operative client on the use of an incentive spirometer. The nurse knows that the correct use of the incentive spirometer is directly related to:
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Solution
Answer D is correct. The correct use of the incentive spirometer will increase the client’s respiratory effort and effectiveness. Answers A and B are indirectly affected by the correct use of the incentive spirometer; therefore, they are incorrect. Answer C is not affected by the use of an incentive spiromenter; therefore, it is incorrect.
The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid:
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Solution
Answer B is correct. The client taking alprazolam should not use alcohol, which includes beer, because alcohol potentiates the effect of the medication. Answers A and D are not associated with the use of alprazolam; therefore, they are incorrect. Answer C is associated with the use of MAO inhibitors; therefore, it is incorrect.
Which snack is best for the child following a tonsillectomy?
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Solution
Answer A is correct. The banana popsicle is best for the child following a tonsillectomy because it is cold and the yellow color does not allow it to be confused with any bleeding that the child might have. Answer B is incorrect because milk products form a film on the operative area and thicken saliva. Answer C is incorrect because fruit punch contains fruit juices that might cause a burning sensation in the throat following a tonsillectomy. Answer D is incorrect because the carbonation from cola causes a burning sensation in the throat following a tonsillectomy.
A client admitted for treatment of a duodenal ulcer complains of sudden sharp midepigastric pain. Further assessment reveals that the client has a rigid, boardlike abdomen. The nurse recognizes that the client’s symptoms most likely indicate:
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Solution
Answer A is correct. Perforation of a duodenal ulcer is characterized by sudden sharp midepigastric pain caused by the emptying of duodenal contents into the peritoneum. The abdomen is tender, rigid, and boardlike. Answer B is not associated with the client’s sudden onset of symptoms; therefore, it is incorrect. Answer C is incorrect because the client would complain of heartburn or reflux. Answer D is incorrect because the client would have increased abdominal distention, visible peristaltic waves, and high-pitched bowel sounds.
The physician has ordered a daily dose of Tagamet (cimetidine) for a client with gastric ulcers. The nurse should administer the medication:
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Solution
Answer C is correct. It is recommended that a daily dose of cimetadine be given at bedtime. Answers A, B, and D are inaccurate times; therefore, they are incorrect.