Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?
A) Deep veins of the legs
B) Bone marrow
C) Myocardial tissue
D) Superior vena cava
B
Feedback:
A fat embolus usually occurs after a fracture or repair to the long bones. Pulmonary emboli may arise from the endocardium of the right side of the heart, but a myocardial infarction has not been identified in this client. The deep veins of the legs are a common site for emboli formation especially with prolonged inactivity or thrombophlebitis, which does not apply to this client.
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The nurse is preparing to administer a viscous medication via the intramuscular route to a small, thin, elderly client. What size needle would the nurse use?
1. 2-inch 18-gauge 2. 1 1/2-inch 20-gauge 3. 1 1/2-inch 18-gauge 4. 2-inch 22-gauge
The nurse is preparing to discuss the cultural implications associated with eye diseases with a small group of nursing students. Which of the following statement indicates that the nurse requires further education about this subject?
1. "It is important to assess the African American client for clinical manifestations associated with increased intraocular pressure.". 2. "We should assess serum glucose levels in our adult Hispanic clients.". 3. "Our diabetic clients should return every 2 years for an assessment of their vision and their retina.". 4. "Poorly controlled serum glucose levels can result in retinal changes that affect the client's vision and can even result in blindness.".
The client receiving intravenous chemotherapy asks the nurse why the nurse is wearing a mask, gloves, and gown when giving the drugs to the client. What is the nurse's best re-sponse?
A. "These drugs will reduce your immune response and, with these coverings, I am protecting you from getting an infection from me." B. "Because your immunity is reduced by this therapy, I am preventing the spread of infection from you to me or any other client here." C. "The hospital policy is for any nurse giving these drugs to wear a gown, glove, and mask to prevent other people from getting cancer." D. The drugs are powerful and I handle them every day. The clothing protects me from accidentally absorbing these strong, cancer-killing drugs."
The nurse is explaining the characteristics of a malignant tumor to a patient who is newly diagnosed with cancer. What should the nurse include in this explanation? (Select all that apply.)
a. The growth rate is rapid. b. Tissue damage is minimal. c. The cells resemble the tissue of origin. d. The cells may invade surrounding tissues. e. The cells can travel to distant organs and initiate new tumors.