A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.

Exhibits

For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Place the client on droplet precautions.

Insert an indwelling urinary catheter.

Place the client in a private room

Check the client's rectal temperature once daily.

Rinse the client's mouth with 0.9% sodium chloride every 4 hours

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.

A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.

The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.

Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.

Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.

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Correct Answer is C

Explanation

A. Thiamine deficiency is often associated with neurological symptoms, such as Wernicke-Korsakoff syndrome, rather than spontaneous bleeding or bruising. Thiamine does not directly impact the coagulation process.
B. Vitamin C deficiency can lead to scurvy, which includes symptoms such as bleeding gums and poor wound healing. However, it is not typically associated with the spontaneous bleeding and bruising seen in chronic liver failure.
C. Vitamin K is essential for the synthesis of clotting factors produced by the liver. In chronic liver failure, the liver's ability to produce these factors is impaired, leading to an increased risk of bleeding and bruising due to vitamin K deficiency.
D. Folic acid deficiency is more commonly linked to anemia and certain neurological issues, but it does not cause spontaneous bleeding or bruising. It does not directly affect coagulation factors as vitamin K does.

A. Clay-colored stools B. Tenderness in the left upper abdomen C. Ecchymosis of the extremities D. Straw-colored urine

Correct Answer is A

Explanation

A. Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
B. Tenderness in the left upper abdomen is more commonly associated with issues such as splenic or gastric problems rather than a bile duct obstruction.
C. Ecchymosis of the extremities is not typically associated with bile duct obstruction. It might indicate other issues such as bleeding disorders.
D. Straw-colored urine is not indicative of bile duct obstruction; typically, the urine would appear darker due to elevated bilirubin levels from bile duct obstruction.

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A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer. Exhibits For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with chronic liver failure who tells the nurse he is experiencing spontaneous episodes of bleeding and has noted increased areas of bruising on his arms. The nurse suspects the client has a deficiency in which of the following vitamins?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.

Exhibits

For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.