The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Fluid accumulation under the arm.

Drainage from the area.

Reddened area around the breast.

Enlargement of the arm or hand.

Answer and Explanation

The Correct Answer is A

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

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Correct Answer is C

Explanation

Tinnitus and sensorineural hearing loss. Salicylates, loop diuretics, quinidine, quinine, or aminoglycosides can cause ototoxicity, which includes tinnitus (ringing in the ears) and sensorineural hearing loss. Therefore, the nurse should monitor the client for auditory changes and report them to the healthcare provider immediately.

Option A, impaired facial movement, is incorrect because it is a sign of facial nerve paralysis, which can occur due to Bell's palsy, stroke, or brain injury.

Option B, signs of hypotension, is incorrect because it can be caused by antihypertensive drugs or dehydration, not the drugs listed.

Option D, reduced urinary output, is incorrect because it can be a sign of acute kidney injury or dehydration, not the drugs listed.

A. Obtain a glucometer reading. B. Administer fruit juice. C. Start an IV of dextrose. D. Call the physician.

Correct Answer is A

Explanation

choice A, Obtain a glucometer reading. The immediate action taken by the nurse is to obtain a glucometer reading to determine the client's blood glucose level. The client's symptoms are suggestive of hypoglycemia, a condition that can lead to coma and seizures if left untreated. Administering fruit juice or starting an IV of dextrose without first checking the client's blood glucose level can worsen the condition if the client's blood glucose is high. The physician should be notified if the client's blood glucose level is critically low or high and if the client's condition does not improve after treatment.
B. Administering fruit juice can worsen the condition if the client's blood glucose is high.
C. Starting an IV of dextrose can worsen the condition if the client's blood glucose is high.
D. Calling the physician is not the immediate action, as the client needs urgent treatment.

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The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Correct Answer is C

Explanation

On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Correct Answer is A

Explanation

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of leaking of cerebral spinal fluid (CSF)?

A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylate toxicity (salicylism)?

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

Following a serious thermal burn, which complication will the nurse take action to prevent first?

The nurse is caring for a client with a degenerative joint disorder and is providing education about different medications that may be used to help the disorder. The nurse provides education for (SATA):.

A client on a prescribed medication for a skin disorder visits the clinic complaining of a skin rash. Which of the following would explain the client's condition?

Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

An older adult male client is participating in a bladder retraining program as part of the treatment for urinary incontinence. The nurse advises him to wear barrier garments, such as liners and protective pants. Which suggestion would be most appropriate to help the client maintain skin integrity?