Week 4 exam

A client has continuous bladder irrigation afdter surgery yesterday. The amount of bladder irrigating solution that has infused over the past 12 hours is 1100 ml. The amount of fluid in the urinary drainage bag is 1950 ml. The nurse records that the client had ________ ml urinary output in the past 12 hours

850

A client who is scheduled for a pap smear reports having had sexual intercourse 1 day prior and douching afterwards. What is the appropriate nursing action? A. reschedule the pap smear for another week B. Delay the procedure until later in the afternoon C. help the client prepare for the procedure at this time D. Hold the procedure until the clients next menstrual cycle

A reschedule the pap smear for another week A pap test should be scheduled between the patient's menstrual periods so the menstrual flow does not interfere with lab analysis. Teach women not to douche, use vaginal medications, powders, or deodorants, or have sexual intercourse for at least 24 hours before the test because these may interfere with test interpretation.

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? SATA A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine.

A, B Furosemide is ototoxic Light reflexes are absent or in altered positions in a client who has a middle ear disorder Meclizine is prescribed to relieve vertigo from ear infections but not pain.

A nurse is reviewing the medical record of a client who has premenstrual syndrome (PMS). The nurse should identify that which of the following medications are used to treat PMS. A. Fluoxetine B. Spironolactone C. Ethinyl estradiol/drospirenone D. Ferrous Sulfate E. Methylergonovine

A, B, C

A nurse is caring for a client who has breast cancer and asks why the treatment plan contains a combination therapy of cyclophosphamide, methotrexate, and fluoracil. The response by the nurse should include that combination chemotherapy is used to do which of the following? SATA A. Decrease medication resistance B. Attack cancer cells at different stages of cell growth. C. Block chemotherapy agents from entering healthy cells D. Stimulate immune system E. Decrease injury to normal body cells

A, B, E Chemotherapy agents are not blocked from entering healthy cells during combination therapy. Cancer Chemotherapy with a combination of cytotoxic agents often causes infection rather than stimulating the immune system.

Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? SATA A. I am so glad this condition will go away permanently B. It is important that I do not drive when I have tinnitus C. Watching my diet will make a difference in my condition D. Surgery is the only treatment that is available for tinnitus E. I have found a couple of support groups that I like to attend

A, C, D

Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A, C, D, E

What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with Meniere disease? SATA A. Reducing activity can reduce frequency of episodes B. Episodes will eventually decrease in severity and number C. Reducing sodium, caffeine, and alcohol intake can be beneficial D. The only treatment that is effective is to undergo labyrinthectomy E. When moving from sitting to standing, be cautious and take your time

A, C, E

A nurse is caring for a client who has a new prescription for oxytocin to stimulate uterine contractions. Which of the following actions should the nurse take? SATA A. Use and infusion pump for medication administration B. Obtain vital signs frequently and with every dosage change. C. Stop infusion if uterine contractions occur every 4 min and last 45 seconds D. Increase medication infusion rate rapidly. E. Monitor fetal heart rate continuously.

A. B. E. Infusion should not be stopped because therapeutic effect has not been achieved Oxytocin rate is increased gradually (not rapidly) to prevent hypertonic uterine contractions.

A nurse is explaining the mechanism of action of combination oral contraceptives to a group of clients. The nurse should tell the clients that which of the following actions occur with the use of combination oral contraceptives? SATA A. Thickening the cervical mucus B. Inducing maturation of ovarian follicle C. Increasing development of the corpus luteum D. Altering the endometrial lining E. Inhibiting ovulation

A. D. E. inducing maturation of ovarian follicle is not an action of oral contraceptives Increasing the development of the corpus luteum is not a

What is the appropriate nursing response when a 66-year old healthy client asks how often a visit to the eye care provider is recommended? A. annually B. every 6 months C. Only if you have vision problems D. Every 3 to 5 years if you have no eye problems

A. Annually Eye care providers recommend that adults older than 40 have an eye exam annually that includes assessment of intraocular pressure and visual fields because the risk for both glaucoma and cataract formation increases with age.

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. I should restrict rapid movements and avoid bending from the waist for several weeks B. I should wait until the day after surgery to wash my hair C. I will remove the dressing behind my ear in 7 days D. My hearing should be back to normal right after surgery

A. I should restrict rapid movements and avoid bending from the waist for several weeks. Rapid movements and bending from the waist should be avoided for 3 weeks following ear surgery.

Which supplement will the nurse recommend to a client who wants to enhance eye health? A. Lutein B. Vitamin D C. Magnesium D. Saw Palmetto

A. Lutein Some nutrients and antioxidants such as lutein, zeaxanthin, and beta carotene help maintain retinal function.

A nurse in a providers office is reviewing the medical record of a client who has fibrocystic breast condition. Which of the following findings should the nurse expect? A. Palpable rubberline lump in the upper outer quadrant B. BRCA1 gene mutated C. Elevated CA-125 D. Peau d'orange dimpling of the breast.

A. Palpable rubberlike lump in the upper outer quadrant Clients who have fibrocystic breast condition typically have breast pain and rubbery palpable lumps in the upper outer quadrant of the breasts.

A nurse is preparing to administer cyclophosphamide IV to a client who has Hodgkin's disease. Which of the following medication should the nurse expect to administer concurrently with the chemotherapy to prevent an adverse effect of cyclophosphamide? A. Protectant agent, such as mesna B. Opioid, such as morphine C. Loop diuretic, such as furosemide D. H1 receptor antagonist, such as diphenhydramine

A. Protectant agent, such as mesna Mesna is a uroprotectant agent that can help prevent hemorrhagic cystitis when administered IV with a nitrogen mustard chemotherapy medication.

The nurse hears a patient tell her partner that condoms with spermicide are important to protect themselves from sexually transmitted infections. What is the appropriate nursing response? A. Teach that spermicide has not been shown to be effective in STI prevention B. do nothing because the nurse should not be listening to the clients conversation C. Educate that spermicide must be used with water based lubricant to be effective D. Affirm that spermicide helps to block transfer of sexually transmitted organisms

A. Teach that spermicide has not been shown to be effective in STI prevention

A nurse is teaching a client about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? A. This medication will stop my contractions B. This medication will prevent vaginal bleeding C. This medication will promote blood flow to my baby D. This medication will increase my prostaglandin production

A. This medication will stop my contractions Terbutaline blocks beta adrenergic receptors, which causes uterine smooth muscle relaxation.

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. use pictures and writing B. Speak with enunciated words C. Ask client to read the nurses lips D. Dialogue with the clients caregivers

A. Use pictures and writing

A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about postoperative care. Which of the following information should the nurse include in the teaching? A. You might have a continuous sensation of needing to void even though you have a catheter. B. you will be on bed rest for the first 2 days after the procedure C. You will be instructed to limit your fluid intake after the procedure. D. Your urine soul be clear yellow the evening after the surgery.

A. You might have a continuous sensation of needing to void even though you have a catheter To reduce the risk of postoperative bleeding, the client will have a catheter with a large balloon that places pressure on the internal sphincter of the bladder. Pressure on the sphincter causes a continuous sensation of needing to void.

The nurse is preparing a client for surgery related to ovarian cancer. When the client states, "im just going to die anyways, why do I even need this surgery?" A. we dont know that you will die from this B. Are you thinking of canceling the surgery? C. Ovarian cancer has an unfavorable prognosis D. if the condition is fatal, hospice can provide care.

A. are you thinking of canceling the surgery?

The nurse is caring for a client who reports beginning to transition from male to female. Which nursing action is appropriate regarding pronoun use? A ask the patient which pronouns are preferred and use those. B. implement use to h/him pronouns as the clients natal sex is male C. use miss or Mrs. since the client has begun the transition to female. D Document that male or female pronouns are appropriate to use at this time.

A. ask the patient which pronouns are preferred and use those.

When caring for a 28 year old healthy client, how frequently does the nurse recommend a clinical breast exam? A. every 3 years B. at each annual physical C. not until age 30 as the risks are low D. to begin at age 40 when risks increase

A. every 3 years it is recommended that the CBE be part of a periodic health assessment, at least every 3 years for women in their 20s and 30s and every year for asymptomatic women at least 40 years of age

What teaching will the nurse provide to a 30 year old female client who has never been sexually active about decreasing her risk of developing cervical cancer? SATA A. You cannot lower the risk of cervical cancer B. you cannot receive the Gardasil 9 immunization C. use condoms when you plan to be sexually intimate D. over the counter contraceptive methods can be used to prevent HPC E. having an annual pap test will decrease your chances of cervical cancer

B, C

A nurse is providing discharge instructions to a client who is postoperative following a TURP. Which of the following instruction should the nurse include? A. Avoid sexual intercourse for 3 months after surgery B. If urine appears bloody, stop activity and rest. C. Avoid drinking caffeinated beverages. D. Take a stool softener once a day E. Treat pain with ibuprofen

B, C, D

Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? SATA A. encourage client to accept her new body image B. provide self-care resources to the primary caretaker C. teach client about birth control options that are available D. refer to support groups for people who have had mastectomy E. involve partner in discussions about sexuality if client desires

B, C, D, E

A nurse is teaching a client who has breast cancer about tamoxifen. Which of the following adverse effects of tamoxifen should the nurse discuss with the client? A. Irregular heart rate B. Abnormal uterine bleeding C. Yellow sclera or dark-colored urine D. Difficulty swallowing

B. Abnormal uterine bleeding Vaginal discharge and bleeding are adverse effects of tamoxifen. The client who takes tamoxifen is also at increased risk for endometrial cancer, so any abnormal uterine bleeding should be carefully monitored and evaluated.

The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. I can have sex up to 8 hours after taking the drug B. i might get a headache or stuffy nose when this drug is used C. taking this with a drink or 2 of alcohol will enhance my performance. D. if one pill doesn't work it is acceptable for me to quickly take another pill

B. I might get a headache or stuffy nose when this drug is used.

The nurse has provided teaching to a client with vulvovaginitis. Which client statement indicates that nursing intervention is required? SATA A. I will wipe from the front to the back B. I will wash with fragranced soap to prevent odor C. I am going to the store now to buy cotton underwear D. I will use fragrance free laundry detergents in the future E. I am going to take all of the medicine the provider prescribed

B. I will wash with fragranced soap to prevent odor

A nurse is providing support to a client who has a new diagnosis of endometriosis. The nurse should inform the client that which of the following conditions is a possible complication of endometriosis? A. Insulin resistance B. Infertility C. Vaginitis D. Pelvic inflammatory disease

B. Infertility Infertility is a complication of endometriosis because endometrial tissue overgrowth can block the fallopian tubes.

A nurse is caring for a client who has angina and asks about obtaining a prescription for sildenafil to treat erectile dysfunction. Which of the following medication is contraindicated with sildenafil? A. Aspirin B. Isosorbide C. Clopidogrel D. Atorvastatin

B. Isosorbide Isosorbide is an organic nitrate that manages pain from angina. Concurrent use of it is contraindicated because fatal hypotension can occur. The client should avoid taking a nitrate medication for 24 hours after taking isosorbide.

The nurse is caring for a client who had a vaginoplasty yesterday. Which assessment finding will the nurse report to the HCP? A. perineal pain B. lower extremity swelling C. constipation D. urinary retention

B. Lower extremity swelling. Post op complications of vaginoplasty surgery include lower extremity compartment syndrome

A nurse is instructing a client who has a new prescription for tomolol how to insert eye drops. The nurse should instruct the client to press on which of the following areas to prevent systemic absorption of the medication? A. Bony Orbit B. Nasolacrimal Duct C. Conjunctival sac D. Outer canthus

B. Nasolacrimal duct. pressing the nasolacrimal duct blocks the lacrimal punctum and prevents systemic absorption of the medication.

A nurse in a clinic is reviewing the facility's testing process and procedures for human immune deficiency virus with a new employee. Which of the following information should the nurse include? A. In the presence of HIV, the enzyme immunoassay test is typically reactive within 72 hours after the client is infected B. The western blot assay is used to confirm the diagnosis of HIV C. The polymerase chain reaction test is used to confirm diagnosis of HIC D. CD4+ cell counts will be elevated in a client who is infected with HIV

B. The western blot assay is used to confirm diagnosis of HIV Confirming HIV is a two-step process. If the EIA is positive, a second test (Western blot) is done

A nurse is providing instructions to a client prior to an initial mammogram. Which of the following information should the nurse provide prior to the procedure? A. You should not take any aspirin products prior to the mammogram B. Do not use or apply any deodorant the day of the exam C. You will need to avoid sexual intercourse the day before the mammogram D. You should avoid exercise prior to the exam.

B. You should not use or apply any deodorant the day of the exam. Applying deodorant or powder can alter the accuracy of a mammogram by causing a shadow to appear.

The nurse is caring for a 33 year old female client who has been intimate with women and men. What teaching will the nurse provide regarding the Gardisil 9 vaccine? A. patients older than 26 cannot receive an HPV vaccine B. You will need 3 doses of the vaccine instead of 2 C. I will give you a single dose and you will be protected from future HPV D. HPV vaccines must be administered to people who have never had intercourse.

B. You will need 3 doses of the vaccine instead of 2

The nurse is caring for a client who just had a laparoscopic total abdominal hysterectomy. Which assessment finding requires immediate nursing intervention? A. temperature of 99.2 B. one saturated perineal pad per hour C. decreased bowel sounds in all quadrants D. report of pain level of 5 on a scale of 0 to 10

B. one saturated perineal pad per hour Perineal pads for vaginal bleeding and clots should be less than one saturated perineal pad in 4 hours

A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. taking ibuprofen may help alleviate the pain B. please go to your closest ED right away C. this is a common reaction when performing labor, the pain will go away. D. Your BPH is probably giving you difficulty because you were moving furniture

B. please go to your closest ED right away

The nurse is caring for a client who has just been diagnosed with primary syphilis. Which client statement reflects that teaching has been effective? SATA A. i can resume having intercourse right after this injection B. at least this infection is not as serious as gonorrhea or chlamydia C. Im afraid, but im going to tell my partners about my diagnosis D. after my treatment, I still need several follow up appointments E. I can take acetaminophen if i get a fever and chills after this show. F. I am going to wait here in the clinic 30 mins after the treatment

C, D, E, F

Which nursing action decreases the risk for health care disparities for transgender clients? SATA A. refer to the clients id card for name B. Determine gender ID based on clothing worn C. seek to understand the experience of the transgender client D. apologize several times if the wrong name is used for the client E. On meeting the client, ask what name and which pronouns are desired. F. Explain how the health history and assessment are affected by gender identity

C, E, F

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate IV continuous infusion. Which of the following findings should the nurse report to the provider? A. 2+ deep tendon reflexes B. 2+ pedal edema C. 24 ml/hr urinary output D. Respirations 12/min

C. 24 ml/hr urinary output Urine output less that 25 to 30 ml/hr is associated with magnesium sulfate toxicity and should be reported to the provider.

A nurse is caring for a client who receives rituximab to treat non-Hodgkin's leukemia and who asks the nurse how rituximab works. Which of the following should the nurse include? A. Blocks hormone receptors B. Increases immune response C. Binds with specific antigens on tumor cells D. Stops DNA replication during cell division

C. Binds with specific antigens on tumor cells Rituximab is a monoclonal antibody that binds to specific antigens on B-lymphocytes and then destroying cancer cells.

A nurse is preparing to discharge a client following an anterior and posterior colporrhaphy. Which of the following instructions should the nurse provide? A. Do not bend over for at least 6 weeks B. You can lift objects as heavy as 10 pounds C. Do not engage in intercourse for at least 6 weeks D. You might have foul smelling drainage for the first week after surgery.

C. Do not engage in intercourse for at least 6 weeks The client should refrain from intercourse to allow time for the surgical site to heal, which is typically about 6 weeks.

A nurse in a providers office is reviewing a clients laboratory results, which shows a positive rapid plasma regain. Which of the following tests will be administered to confirm the diagnosis of syphilis? A. VDRL B. D Dimer C. Fluorescent treponemal antibody absorbed (FTA- ABS) D. Sickledex

C. FTA-ABS The fluorescent treponemal antibody absorbed is used to confirm toe diagnosis of syphilis

What finding does this nurse anticipate when assessing a client with a new diagnosis of glaucoma? A. Seeing "shooting stars" B. Decrease in central vision C. Gradual loss of visual fields D. Abrupt onset of excruciating pain

C. Gradual loss of visual fields

A nurse is providing teaching to a client who will start alfuzosin for treatment of benign prostatic hyperplasia. The nurse should instruct the client that which of the following is an adverse effect of this medication? A. Bradycardia B. Edema C. Hypotension D. Tremor

C. Hypotension Alfuzosin relaxes muscle tone in veins and cardiac output decreases, which leads to hypotension. Clients taking this medication are advised to rise slowly from a sitting or lying position.

A nurse is performing a preoperative assessment for a client who is scheduled for an anterior colporrhaphy. Which of the following client statements should the nurse expect as an indication for this procedure? A. I have to push the feces out of a pouch in my vagina with my fingers B. I have pain and bleeding when I have a bowel movement C. I have had frequent urinary tract infections D. I am embarrassed by uncontrollable flatus

C. I have had frequent urinary tract infections Due to urinary stasis associated with a cystocele, this finding is an expected finding of a cystocele. The surgery for a cystocele is an anterior colporrhaphy.

A nurse is reviewing a new prescription for terbutaline with a client who has a history of preterm labor. Which of the following client statements indicates understanding of the teaching? A. I can increase my activity now that I've started on this medication B. I will increase my daily fluid intake to 3 quarts C. I will report increasing intensity of contractions to my doctor D. I am glad this will prevent preterm labor

C. I will report increasing intensity of contractions to my doctor. The client should report increasing intensity, frequency, or duration of contractions to the provider because these are manifestations of preterm labor.

The nurse notes bright red urinary drainage from a client who had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. What is the appropriate initial nursing action? A. Calculate intake and output. B. Monitor hemoglobin and hematocrit. C. Increase the rate of the bladder irrigation. D. Document findings in the electronic health record.

C. Increase the rate of bladder irrigation

A client has been scheduled for a transvaginal ultrasound. Which allergy does the nurse identify that should be IMMEDIATELY reported to the HCP? A. eggs B. corn C. latex D. iodine

C. Latex Teach the patient to report any allergies to latex, as the condom like sac is often made of latex.

A nurse in an emergency department is reviewing the medical record of a client who is being evaluated for angle closure glaucoma. Which of the following findings are indicative of this condition? A. Insidious onset of painless loss of vision B. Gradual reduction in peripheral vision C. Severe pain around eyes D. Intraocular pressure 12 mmHg

C. Severe pain around eyes Severe pain around the eyes that radiates over the face is a manifestation of acute angle closure glaucoma.

A nurse is providing information to a client who is scheduled for a transrectal ultrasound (TRUS). Which of the following information should the nurse include? A. This procedure will determine whether you have prostate cancer B . The procedure is contraindicated if you have an allergy to eggs C. Sound waves will be used to create a picture of your prostate D. You should avoid having a bowel movement for 1 hr prior to the procedure.

C. Sound waves will be used to create a picture of your prostate. A transrectal ultrasound creates an image of the prostate using sound waves

A 68 year old client who has had normal pap results for 10 years and no history of cancer asks about scheduling a pap smear. Which nursing response is appropriate? A. You will need a pap test this year B. You arent due for a pap test until next year C. You do not need to have further pap tests at this time D. You do not need a pap test unless you are sexually active

C. You do not need to have further pap tests at this time Women older than 65 years who have had regular cervical cancer testing with normal results in the past decade and no serious cancers in the past 20 years do not need further pap testing

A nurse is providing education to a client prior to an initial pap test. Which of the following statements should the nurse make? A. you should urinate immediately after the procedure is over B. You will not feel any discomfort C. You may experience some bleeding after the procedure. D. You will need to hold your breath during the procedure.

C. You may experience some bleeding after the procedure. The client can experience a small amount of vaginal bleeding due to scraping of the cervix.

A nurse is teaching a client who has a new prescription for brimonidine opthalmic drops and wears soft contact lenses. Which of the following instructions should the nurse include in the teaching? A. This medication can stain your contacts B. This medication can cause your pupils to contract C. This medication can absorb into your contacts D. This medication can slow your heart rate

C. this medication can absorb into your contacts Brimonidine can absorb into soft contact lenses. The client should remove their contacts then instill the medication and wait at least 15 mins before putting the contacts back in.

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? SATA A. hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

C., E

When caring for four clients, which client does the nurse report to the healthcare provider who should NOT receive an otoscopic examination? A. 25 year old with throat and ear pain B. 39 year old experiencing dizziness C. 46 year old who has type 2 diabetes D. 60 year old experiencing delirium

D. 60 year old experiencing delirium

Which patient does the nurse identify at highest risk for development of dry age related macular degenerative disease? A. 55 year old client who recently began wearing glasses B. 59 year old client who has controlled hypertension C. 62 year old client with hypothyroidism D. 65 year old client with diabetes

D. 65 year old client with diabetes Clients who are over 60 years old, and are diabetic, hypertensive, or Caucasian are at highest risk for dry AMD

What teaching will the nurse provide to a client who has not been fitted for new hearing aids? A. Turn off the hearing aid when not using it B. Immerse the ear mold in alcohol C. Store the hearing aid in a warm, humid bathroom when not in use D. Avoid using hair spray, makeup, and personal care products around the device

D. Avoid using hair spray, makeup, and personal care products around the device.

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. pearly gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid or bubbles seen behind the TM

D. Fluid or bubbles seen behind the TM Fluid behind the TM indicates the possibility of otitis media and is not an expected finding.

A nurse is preparing to administer leucovorin to a client who has cancer and is receiving chemotherapy with methotrexate. Which of the following responses should the nurse use when the client asks why leucovorin is being given? A. Leucovorin reduces the risk of a transfusion reaction from methotrexate B. Leucovorin increases platelet production and prevents bleeding C. Leucovorin potentiates the cytotoxic effects of methotrexate D. Leucovorin protects healthy cells from methotrexate's toxic effects.

D. Leucovorin protects healthy cells from methotrexate's toxic effects Leucovorin, a folic acid derivative and an antagonist to methotrexate, is given within 12 hours of high doses of methotrexate to protect healthy cells from the toxic effects of methotrexate.

A nurse is reviewing the medical record of a client who has a cystocele. Which of the following findings should the nurse identify as a risk factor for the development of this disorder? A. BMI of 18 B. Nulliparity C. Chronic constipation D. Postmenopausal

D. Postmenopausal Identify that the advancing age and loss of estrogen that correlate with postmenopausal status are risk factors for the development of a cystocele

A nurse is caring for a client who has a new diagnosis of BPH. The nurse should expect a prescription for which of the following medications? A. Oxybutynin B. Diphenhydramine C. Ipratripium D. Tamsulosin

D. Tamsulosin Tamsulosin is an alpha-adrenergic receptor antagonist that relaxes the bladder outlet and the prostate gland, which improves urinary flow.

A nurse is reviewing the health care record of a client who is asking about conjugated equine estrogens. The nurse should inform the client this medication is contraindicated in which of the following conditions? A. Atrophic vaginitis B. Dysfunctional uterine bleeding C. Osteoporosis D. Thrombophlebitis

D. Thrombophlebitis Estrogen increases the risk of thrombolytic events. Estrogen use is contraindicated for a client who has a history of thrombophlebitis.

A nurse is teaching a client about preventing otitis externa. Which of the following instructions should the nurse include? A. Clean the ear with a cotton tipped swab daily B. Place earplugs in the ears when sleeping at night C. Use a cool water irrigation solution to remove earwax D. Tip the head to the side to remove water from the ears after showering.

D. Tip the head to the side to remove water from the ears after showering. The client should remove water from the ear after showering or swimming to reduce the risk for otitis externa.

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

D. Unilateral hearing loss This is an expected finding in Meniere's disease

A nurse in a provider's office is obtaining a history from a client who is undergoing an evaluation for benign prostatic hyperplasia. (BPH). The nurse should identify that which of the following findings are indicative of this condition? SATA A. Backache B. Frequent urinary tract infections C.Weight loss D. hematuria E. urinary incontinence

B, D, E

A school nurse is providing an education session about menstruation with a group of adolescent students. Which of the following statements should the nurse include? SATA A. The average age of onset of menstruation is 10 B. The range for a typical menstrual cycle is between 23 and 35 days C. The first day of the menstrual cycle begins with the last day of the menstrual period D. Ovulation typically occurs around the 14th day of the menstrual cycle E. A menstrual period can last as long as 9 days

B, D, E

A nurse is instructing a client how to perform Kegel exercises. Which of the following instructions should the nurse include? SATA A. percorm exercises about 50 times each day. B. Contract the circumvaginal and or perirectal muscles C. Gradually increase the contraction period to 10 seconds D. Follow each contraction with at least a 10 second relaxation period E. Perform while sitting, lying, and standing F. Tighten abdominal muscles during contractions

A, B, C, D, E Dont tighten abdominal muscles during contractions

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? SATA A. Reduce exposure to bright lighting B. Move head slowly when changing positions C. Do not eat fruit high is potassium D. Plan evenly spaced daily fluid intake E. Avoid fluids containing caffeine.

A, B, D Avoid foods containing high levels of sodium, not potassium, to reduce fluid retention which can cause vertigo. Avoid caffeine or alcohol, they increase vertigo

The nurse is caring for a client who underwent a hysterosalpingogram earlier in the day. Which assessment finding will the nurse immediately report to the HCP? SATA A. fever and chills B. heart rate 120bpm C. Bloody vaginal discharge D. pain in the lower quadrant E. discomfort in the shoulder

A, B, D Instruct patients to contact the health care provider if bloody discharge continues for 4 days or longer and to immediately report any signs of infection, such as lower quadrant pain, fever, chills, malodorous discharge, or tachycardia

A nurse at a providers office is caring for an older adult client who is having an annual physical exam. Which of the following findings indicates additional follow up is needed to regard to the prostate gland? SATA A. Prostate specific antigen (PSA) is 7.1 ng/mL B. A digital rectal exam (DRE) reveals an enlarged and nodular prostate C. The client reports a weak urine stream D. The client reports urinating once during the night E.Smegma is presne tbelow the glans of the penis

A, B, C

Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? SATA A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0 F E. Pupil that constricts in response to light

A, B, C

A nurse is caring for a client who is in labor and is receiving oxytocin. The nurse should monitor the client for which of the following as complications of oxytocin? SATA A. Uterine rupture B. Uterine tachysystole C. Placental abruption D. Hyponatremia E. Placenta previa

A, B, C, D Placenta previa is not a complication of oxytocin administration.

A nurse is a providers office is providing information to a client who has dysfunctional uterine bleeding. Which of the following statements by the client indicates and understanding of the information? SATA A. my heavy bleeding can be due to a hormonal imbalance B. if I experience menstrual pain, I should take aspirin C. Oral contraceptives are contraindicated for clients who have heavy uterine bleeding like mine D. My doctor can perform a D & C to find out what's causing my abnormal bleeding E. My condition is more common in clients who are in their 30s

A, D

The nurse has delegated care for a client with a radical left mastectomy for breast cancer to assistive personnel. Which AP action requires nursing intervention? A. obtains blood pressure via left arm B. reports clients pain level to the nurse C. applies gait belt prior to walking with the client D. records vital signs in the electronic health record

A, E

Which teaching will the nurse provide to a client who has been prescribed antibiotics for pelvic inflammatory disease? SATA A. Finish all of the prescribed drug even if you begin to feel better B. if you feel nauseated from the antibiotics, take a dose of Tums or Maalox C. Take antibiotics with food to decrease the chance of stomach irritation D. You may resume intercourse once you have been on the antibiotic for 48 hours E. You will need to return to see the CHP after finishing drug therapy

A, E

A nurse in a providers office is instructing a guardian of a toddler how to administer ear drops. Which of the following instructions should the nurse include? SATA A. Place the child on the unaffected side when you are ready to administer the medication B. Warm the medication by gently rolling it between your hands for a few mins. C. Gently shake medication that is in suspension form D. Keep the child on their side for 5 mins after instillation of the ear drops. E. Tightly pack the ear with cotton after instillation of the ear drops.

A. B. C. D. Cotton should be loosely packed, not tightly packed.

A nurse is providing teaching to a female client who is taking testosterone to treat advanced breast cancer. The nurse should tell the client that which of the following are adverse effects of this medication? SATA A. Deepening Voice B. Weight Gain C. Low blood pressure D. Dry mouth E. Facial hair

A. B. E. High blood pressure, not low is an adverse effect of this medication Nasal congestion, not dry mouth is an adverse effect

A client is scheduled for a transvaginal surgical repair this morning. Which assessment finding requires immediate nursing intervention? A. notation of surgery type with mesh B. expression of fear prior to procedure. C. blood pressure 140/92, P 88, R 20, T. 98.8 D. Client request for caregiver to come to PACU

A. notation of surgery type with mesh mesh intended for transvaginal surgical repair was discontinued in the US in 2019 because of complications associated with this procedure.

A nurse is providing teaching for a client who is to undergo a cervical biopsy. Which of the following information should the nurse include?SATA A. The procedure is painless B. Avoid heavy lifting for approximately 2 weeks after the procedure C. Heavy bleeding is common during the first 12 hours after the procedure. D. Avoid the use of tampons for 2 weeks after the procedure.

B, D

A nurse is reviewing the medical record of a client who is menopausal. Which of the following findings should the nurse expect? SATA A. Increased vaginal secretions B. Decreased bone density C. Increased HDL level D. Decreased skin elasticity E. Increased pubic hair growth F. Decreased follicle stimulating hormone level

B, D

A nurse is caring for a client who is being treated with interferon alfa-2b for malignant melanoma. For which of the following adverse effects should the nurse monitor? SATA A. Tinnitus B. Muscle aches C. Peripheral neuropathy D. Bone loss E. Depression

B, C, E Tinnitus is not an adverse effect of interferon alfa-2b Bone loss can occur from treatment with gonadotropin-releasing hormone agonists (leuprolide). Bone loss does not occur with interferon alfa 2-b treatment.

Which client statement affirms that nurse teaching about instillation of multiple different eyedrops has been effective? SATA A. It will be very easy for me to instill all of the drops at one time B. A schedule will help me remember when to instill the eyedrops C. If I have trouble instilling the drops, there are devices that can be helpful D. I can label the eyedrops by color to help me easily distinguish which one is which E. I will not touch the droppers to my eyes as this can cause contamination and infection

B, C, D, E Instill the drops one at a time, not all at once.

The nurse provides health teaching for a transgender woman receiving estrogen therapy. Which statement by the client indicates a need for further teaching? A. ill call my doctor if I have any redness or swelling in my legs B. Ill have less hair on my body after taking this drug C. i know that the drug will make my breasts bigger D. i think i will have more sex drive when taking this drug

D. i think i will have more sex drive when taking this drug Expected changes for feminizing drug therapy includes a decreased libido

A client has undergone a prostate biopsy. Which post procedure symptom will the nurse teach the client to report immediately to the PCP? A. semen discoloration 5 days after biopsy B. light rectal bleeding 2 days after procedure C. tenderness at the site 1 day after biopsy D. Pain on urination 3 days after procedure.

D. pain on urination 3 days after procedure Teach the patient to contact the HCP if he has fever, prolonged or heavy bleeding, worsening pain, swelling in the area of biopsy, and or difficulty urinating

Which assessment finding will the nurse report to the HCP for a client who had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning? A. BP 130/80 T 98.9, R 16, P 70 B. Urinary catheter draining clear yellow urine C. expresses fearfulness of inability to perform sexually D. Reports pain of 9 on a 0-10 scale after receiving pain medication

D. reports pain of 9 on a 0-10 scale after receiving medication