A patient is taking cholestyramine. The nurse will assess for which of the following common adverse effects of the drug?

A female client who has undergone a right radical mastectomy returns from surgery. Which one of the following nursing actions would be most appropriate?

A) Ask the client how she feels about having her breast removed. B) Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. C) Encourage her to turn, cough, and deep breathe at frequent intervals. D) Lower her right arm below heart level.

An Apgar score of 10 at 1 minute after birth indicates:

1. an infant having no difficulty adjusting to extrauterine life and no further testing needed. 2. an infant in severe distress that needs resuscitation. 3. a prediction of a future free of neurologic problems. 4. an infant having no difficulty adjusting to extrauterine life, but that should be as-sessed again at 5 minutes after birth.

A patient tells the nurse that he hears a loud fire alarm when in reality there is no alarm. The nurse realizes this patient is experiencing:

a. disorientation c. sensory overload b. sensory deprivation d. auditory hallucination

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action?

1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon 2. Exerts a lower osmotic pressure than the surrounding interstitial fluid 3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon 4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon