A client with lung cancer is being cared for by his wife at home. His

Medical Surgical NCLEX RN

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Question 1 of 5.

A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.

A. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock.

B. Administers immediate-release medication (oxycodone) for breakthrough pain.

C. Avoids long-acting opioids due to her concern about addiction.

D. Uses music for distraction as well as heat or cold in combination with medications.

E. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications.

F. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal.

Explanation: Effective pain management includes around-the-clock long-acting opioids (A), immediate-release opioids for breakthrough pain (B), non-pharmacologic methods like music or heat/cold (D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.

Question 2 of 5.

A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:

A. Heart rate irregular with S3.

B. Heart rate irregular with S4.

C. Heart rate irregular with aortic regurgitation.

D. Heart rate irregular with mitral stenosis.

Explanation: An extra heart sound after S2 at the apex, constant through the respiratory cycle, is an S3, often associated with heart failure post-myocardial infarction. Atrial fibrillation causes an irregular heart rate.

Question 3 of 5.

A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse?

A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.'

B. The triglycerides are elevated and will be lowered to normal with these medications.'

C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered.'

D. The medications are not indicated since your lab values are all normal.'

Explanation: Elevated CRP (4.2) indicates inflammation associated with cardiovascular risk. Statins and aspirin reduce inflammation and prevent cardiovascular events, addressing the client's risk profile.

Question 4 of 5.

The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:

A. Minimizing dyspnea.

B. Maintaining adequate blood pressure control.

C. Decreasing myocardial contractility.

D. Preventing fluid volume deficit.

Explanation: Maintaining adequate blood pressure post-PTCA ensures coronary perfusion and prevents complications like stent thrombosis or ischemia.

Question 5 of 5.

The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

A. Assess respiratory status.

B. Draw blood for laboratory studies.

C. Insert a Foley catheter.

D. Weigh the client.

Explanation: Edema and left ventricular enlargement suggest heart failure, which can cause pulmonary edema. Assessing respiratory status first detects signs of respiratory distress.