The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

Degree of upper body vasculature observed.

Arm circumference and degree of edema.

Blood pressure and heart rate.

Peripheral sensation and movement of upper extremities.

Answer and Explanation

The Correct Answer is C

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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Correct Answer is C

Explanation

A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

A. Confusion, Lethargic B. Confusion, Stupor C. Lethargic, Obtunded D. Conscious, Confusion

Correct Answer is A

Explanation

A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.

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The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

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Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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