AH 1 Final - Chapters 18, 20, 21, 61, 62, 65, 66, 67, 68, 69

A client has a positive HSV-2 test but is asymptomatic. What action by the nurse is best? a. Encourage the client to have frequent STI screening. b. Teach the client ways to prevent getting STIs. c. Provide the same education as if the client were symptomatic. d. Inform the client that partner notification is unnecessary.

ANS B

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Cloudy urine b. Urinary hesitancy c. Post-void dribbling d. Weak urinary stream

ANS: A Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Hematuria b. Urinary hesitancy c. Postvoid dribbling d. Weak urinary stream

ANS: A Hematuria, especially at the start or end of the urine stream, could indicate infection due to possible urine retention and would cause the nurse to act promptly. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, postvoid dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

The nurse caring for clients admitted for infectious diseases understands what information about emerging global diseases and bioterrorism? a. Many infections are or could be spread by international travel. b. Safer food preparation practices have decreased foodborne illnesses. c. The majority of Americans have adequate innate immunity to smallpox. d. Plague produces a mild illness and generally has a low mortality rate.

ANS: A Increased global travel has resulted in the spread of many emerging diseases and has the potential to spread diseases caused by bioterrorism. Foodborne illnesses are on the increase. Many people in the United States have never been vaccinated against smallpox, and those who have are not guaranteed life-long protection. Plague can be fatal.

The nurse is reviewing information about FtM gender-affirming surgical options with a client. What statement by the client indicates the need for further information? a. "A penile implant is inserted during the phalloplasty." b. "Vaginal atrophy can occur and lead to itching." c. "I will still need cervical cancer screening if I don't have a total hysterectomy." d. "This surgery will have many psychologic benefits for me."

ANS: A The penile implant or prosthesis is not implanted with the original phalloplasty, but months later when the original operation has healed. The other statements are accurate regarding gender-affirming surgery.

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information? a. "I will be careful if I need enemas for constipation." b. "I will use an electric shaver instead of a razor." c. "I should only eat soft food that is either cool or warm." d. "I won't be able to play sports with my grandkids."

ANS: A The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers. This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the nurse is best? a. Administer bowel cleansing as prescribed. b. Educate the client on immunosuppressive drugs. c. Inform the client he/she will drink a thick liquid. d. Place a nasogastric tube to intermittent suction.

ANS: A The usual route of delivering an FMT is via colonoscopy, so the client would have a bowel cleansing as prescribed for that procedure. The client will not need immunosuppressant drugs, to drink the material, or have an NG tube inserted.

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? a. Request an order for serum electrolytes and uric acid. b. Increase the client's IV infusion rate. c. Instruct assistive personnel to strain all urine. d. Administer an IV antiemetic.

ANS: A This client's reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client's urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Prostate acid phosphatase (PAP) d. C-reactive protein (CRP)

ANS: A AFP is a glycoprotein that is elevated in testicular cancer. PSA and PAP testing is used in the screening of prostate cancer. CRP is diagnostic for inflammatory conditions.

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

ANS: A All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods

ANS: A All methods will help prevent infection; however, health care workers lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects

ANS: A Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the clients own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

ANS: A Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

A 23-year-old female has been diagnosed with genital warts. Which action by the nurse is best? a. Encourage the client to have an annual Papanicolaou (Pap) test. b. Recommend an over-the-counter wart treatment for genital tissue. c. Report the case to the Centers for Disease Control and Prevention (CDC). d. Discuss popular options for contraception.

ANS: A An annual Pap test is recommended (due the strong relationship between genital warts and the development of dysplasia of the cervix) until three normal Pap smears are obtained. The Pap smear can detect any malignancies of the cervix. Prescribed cream or gel such as podofilox (Condylox) is the recommended treatment, but not over-the-counter treatments. Genital warts, or condylomata acuminata, do not have to be reported to the CDC in all states. Pregnancy is not contraindicated with genital warts.

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A student nurse asks why brushing clients teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best? a. It mechanically removes biofilm on teeth. b. Its easier to clean all surfaces with a brush. c. Oral care is important to all our clients. d. Toothbrushes last longer than oral swabs.

ANS: A Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.

A 26-year-old client with multiple sexual partners is being assessed for symptoms of dysuria and vaginal discharge. Because the results from the culture of the cervical cells are not available, the client will be treated for both Chlamydia and gonorrhea. Which explanation by the nurse is best? a. This early treatment will prevent obstruction to the fallopian tubes. b. Only azithromycin (Zithromax) is prescribed for both sexually transmitted diseases. c. The treatment will prevent aortic valve disease and aneurysms. d. Oral antibiotic treatment will prevent frequent occurrences of meningitis.

ANS: A Both gonorrhea and Chlamydia can cause pelvic inflammatory disease and scarring of the fallopian tubes, resulting in infertility problems. Azithromycin is the treatment of choice for both sexually transmitted diseases, but ceftriaxone (Rocephin) is also recommended for treatment of gonorrhea. Aortic valve disease and aneurysms usually occur with tertiary syphilis. Meningitis occurs rarely with a gonorrhea infection and is usually treated with intravenous antibiotic therapy in the hospital setting.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

ANS: A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the clients ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the isolation precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit. d. Notify the physician that the client cannot leave the room for the CT scan.

ANS: A Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I dont need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes

ANS: A Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is best? a. Encourage the client to complete STI screening. b. Recommend an over-the-counter wart treatment for genital tissue. c. Report the case to the Centers for Infection Control and Prevention (CDC). d. Discuss popular options for contraception.

ANS: A Clients with HPV should be fully screened for other STIs since co-infection is common. Over the counter treatments should not be applied to genital tissue. HPV is not reportable. Contraception is not related.

After teaching a client with a history of renal calculi, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I should drink at least 3 liters of fluid every day. b. I will eliminate all dairy or sources of calcium from my diet. c. Aspirin and aspirin-containing products can lead to stones. d. The doctor can give me antibiotics at the first sign of a stone.

ANS: A Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss d. Mucositis

ANS: A Doxorubicin (Adriamycin) can cause cardiac problems with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens.

A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the clients temperature every 4 hours.

ANS: A Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Having a cool, wet cloth on the wound may macerate the broken skin. Taking the clients temperature provides data but does not increase comfort.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline

ANS: A Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding? a. This condition will become malignant over time. b. I should refrain from using hormone replacement therapy. c. One cup of coffee in the morning should be enough for me. d. This condition makes it more difficult to examine my breasts.

ANS: A Fibrocystic breast condition does not increase a woman's chance of developing breast cancer. Hormone replacement therapy is not indicated since the additional estrogen may aggravate the condition. Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.

ANS: A Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

ANS: A For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication.

ANS: A Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with Clostridium difficile. The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.

A client has returned from the post anesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client? a. Apply ice to the perineum. b. Elevate the legs on pillows. c. Position the client on the left side. d. Raise the head of the bed.

ANS: A Ice is applied to the perineum to reduce pain and discomfort. Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism. Positioning the client on the left side and raising the head of the bed are not comfort measures related to this procedure.

A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse? a. You are only reactive when the radioactive implant is in place. b. To be totally safe, it is a good idea to sleep in a separate room. c. It is best to stay a safe distance from friends or family between treatments. d. You should use a separate bathroom from the rest of the family.

ANS: A In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments.

A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority? a. Blood pressure b. Lung assessment c. Oral mucous membranes d. Skin integrity

ANS: A Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments of fluid status take priority.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.

After teaching a client who has stress incontinence, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will limit my total intake of fluids. b. I must avoid drinking alcoholic beverages. c. I must avoid drinking caffeinated beverages. d. I shall try to lose about 10% of my body weight.

ANS: A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a. The treatment reduces testosterone and prevents bone fractures. b. The medications prevent erectile dysfunction and increase libido. c. There is less gynecomastia and osteoporosis with this drug regimen. d. These medications both inhibit tumor progression by blocking androgens.

ANS: A Lupron, an LH-RH agonist, stimulates the pituitary gland to release luteinizing hormone (LH) to the point that the gland is depleted of LH and testosterone production is lessened. This may decrease the prostate cancer since it is hormone dependent. Lupron can cause osteoporosis, which results in the need for Aredia to prevent bone loss. Erectile dysfunction, decreased libido, and gynecomastia are side effects of the LH-RH medications. Antiandrogen drugs inhibit tumor progression by blocking androgens at the site of the prostate.

A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? a. Assess the client frequently for worsening of his or her condition. b. Delegate comfort measures to unlicensed assistive personnel. c. Ensure the client is placed on Contact Precautions. d. Restrict visitors to the immediate family only.

ANS: A Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the clients body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.

A nurse has taken an informed consent to a woman who is having a transvaginal repair of a prolapsed uterus. What client statement indicates a need for more information? a. "The mesh they use may become infected." b. "I may still need to do my Kegel exercises." c. "I will watch for any signs of infection." d. "I know how to use the incentive spirometer."

ANS: A Mesh is not used in the transvaginal approach as it has been discontinued in this country. The other statements show good understanding

A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding? a. Client who has had two saturated perineal pads in the last 2 hours b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg c. Client who has pain of 4 on a scale of 0 to 10 d. Client with a urinary catheter output of 150 mL in the last 3 hours

ANS: A Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.

The nurse has educated a community group of risk factors for ovarian cancer. Which statement by a participant shows the need for reviewing the information? a. "This is a disease of young women." b. "Never being pregnant increases my risk." c. "Difficulty conceiving is a risk factor." d. "Having endometriosis is one of the risks."

ANS: A Ovarian cancer usually strikes women who are middle age or older. Nulliparity, difficulty conceiving, and endometriosis all increase risk and are correct statements.

A client is receiving rituximab. What assessment by the nurse takes priority? a. Blood pressure b. Temperature c. Oral mucous membranes d. Pain

ANS: A Rituximab can cause infusion-related reactions, including hypotension, so monitoring blood pressure is the priority. Other complications of this drug include fever with chills/rigors, headache and abdominal pain, shortness of breath, bronchospasm, nausea and vomiting, and rash. Assessing the client's temperature and for pain are both pertinent assessments, but do not take priority over the blood pressure. Oral mucus membrane assessment is important for clients with cancer, but are not specific for this treatment.

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.

ANS: A Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away. The client may or may not need steroids; they may be given either IV or orally.

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this clients risk factors? a. Do you smoke cigarettes? b. Do you use any alcohol? c. Do you use recreational drugs? d. Do you take any prescription drugs?

ANS: A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement by the client indicates a lack of understanding? a. I need to change my tampon every 8 hours during the day. b. At night, I should use a feminine pad rather than a tampon. c. If I don't use tampons, I should not get TSS. d. It is best if I wash my hands before inserting the tampon.

ANS: A Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus. All of the other responses are correct: use of feminine pads at night, not using tampons at all, and washing hands before tampon insertion are all strategies to prevent TSS.

A nurse is providing health teaching to a middle-aged male-to-female (MtF) client who has undergone gender reassignment surgery. What information is most important to this client? a. Be sure to have an annual prostate examination. b. Continue your normal health screenings. c. Try to avoid being around people who are ill. d. You should have an annual flu vaccination.

ANS: A The MtF client retains the prostate, so annual screening examinations for prostate cancer remain important. The other statements are good general health teaching ideas for any client.

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L Total calcium 12 mg/dL Hematocrit 39% Hemoglobin 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase and calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit and hemoglobin are decreased, indicating anemia. d. The elevated hematocrit and hemoglobin indicate dehydration.

ANS: A The alkaline phosphatase (normal value 30 to 120 U/L) and total calcium (normal value 9 to 10.5 mg/dL) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females.

A nurse reads on a hospitalized clients chart that the client is receiving teletherapy. What action by the nurse is best? a. Coordinate continuation of the therapy. b. Place the client on radiation precautions. c. No action by the nurse is needed at this time. d. Restrict visitors to only adults over age 18.

ANS: A The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this clients teaching? a. Use a second form of birth control while on this medication. b. You will experience increased menstrual bleeding while on this drug. c. You may experience an irregular heartbeat while on this drug. d. Watch for blood in your urine while taking this medication.

ANS: A The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

ANS: A The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? a. I am glad that these tubes will fall out at home when I finally shower. b. I should measure the drainage each day to make sure it is less than an ounce. c. I should be careful how I lie in bed so that I will not kink the tubing. d. If there is a foul odor from the drainage, I should contact my doctor.

ANS: A The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a days time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the doctor should be contacted immediately.

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates the client needs more information? a. "I have to wash the outside of the catheter once a day with soap and water. b. "I should take extra time to clean the catheter site by pushing the foreskin back." c. "The drainage bag needs to be changed at least once a week and as needed." d. "I should pour a solution of vinegar and water through the tubing and bag."

ANS: A The first few inches (centimeters) of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the client? a. I only have to wash the outside of the catheter once a week. b. I should take extra time to clean the catheter site by pushing the foreskin back. c. The drainage bag needs to be changed at least once a week and as needed. d. I should pour a solution of vinegar and water through the tubing and bag

ANS: A The first few inches of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? (Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

ANS: A The nurse has auscultated wheezing in the clients lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. Do any of your family members have this problem? b. Do you drink any cranberry juice? c. Do you urinate after sexual intercourse? d. Do you experience burning with urination?

ANS: A There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a. There should be no problem with a glass of wine with dinner each night. b. I am so glad that I weaned myself off of coffee about a year ago. c. I need to inform my allergist that I cannot take my normal decongestant. d. My normal routine of drinking a quart of water during exercise needs to change.

ANS: A This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the clients gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the clients job risks

ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A client with multiple sexual partners has been assessed for symptoms of dysuria and green, malodorous vaginal discharge. The nurse administers and injection of ceftriaxone and gives the client a prescription for doxycycline. The client asks why two drugs are needed. What answer by the nurse is best? a. "It is very common to be infected with both gonorrhea and chlamydia." b. "Giving two medications increases the chance of curing the infection." c. "Some people are not affected by the injection and need more medication." d. "This will prevent you from needing a 3-month follow-up test."

ANS: A This client has signs of gonorrhea. Co-infection with gonorrhea and chlamydia is common, so the client being treated for gonorrhea also needs treatment for chlamydia with oral antibiotics. It is fairly accurate to say two medications increases the chance of cure, but does not really explain the situation. Giving the client two medications is not because some people are not affected by the injection nor is it to prevent needing a 3-month follow-up test. Testing for re-infection with chlamydia is recommended by the CDC.

A client in the emergency department reports difficulty breathing. The nurse assesses the clients appearance as depicted below: What action by the nurse is the priority? a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Start high-dose steroid therapy.

ANS: A This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.

ANS: A Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.

The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.) a. I should not have any problems driving to see my mother, who lives 3 hours away. b. Now that I have time off from work, I can return to my exercise routine next week. c. My granddaughter weighs 23 pounds, so I need to refrain from picking her up. d. I will have to limit the times that I climb our stairs at home to morning and night. e. For 1 month, I will need to refrain from sexual intercourse.

ANS: A, B Driving and sitting for extended periods of time should be avoided until the surgeon gives permission. For 2 to 6 weeks, exercise participation should also be avoided. All of the other responses demonstrate adequate knowledge for discharge. The client should not lift anything heavier than 10 pounds, should limit stair climbing, and should refrain from sexual intercourse.

A nurse teaches a client about self-management after experiencing a urinary calculus treated by lithotripsy. Which statements would the nurse include in this client's discharge teaching? (Select all that apply.) a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 L of fluid each day." c. "The bruising on your back may take several weeks to resolve." d. "Report any blood present in your urine." e. "It is normal to experience pain and difficulty urinating."

ANS: A, B, C The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 L of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the primary health care provider as these may signal the beginning of an infection or the formation of another stone.

A clients family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the clients right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

ANS: A, B, C The clients right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the clients right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

A woman has been using acupuncture to treat the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.) a. Lymphedema b. Bleeding tendencies c. Low white blood cell count d. Elevated serum calcium e. High platelet count

ANS: A, B, C Acupuncture could be unsafe for the client if there is poor drainage of the extremity with lymphedema or if there was a bleeding tendency and low white blood cell count. Coagulation would be compromised with a bleeding disorder, and the risk of infection would be high with the use of needles. An elevated serum calcium and high platelet count would not have any contraindication for acupuncture.

A student nurse is learning about the health care needs of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients. Which terms are correctly defined? (Select all that apply.) a. Gender dysphoria Distress caused by incongruence between natal sex and gender identity b. Gender queer A label used when gender identity does not conform to male or female c. Natal sex The sex one is born with or is assigned to at birth d. Transgender A person who dresses in the clothing of the opposite sex e. Transition The time between questioning and establishing a sexual identity

ANS: A, B, C Gender dysphoria is emotional distress caused by the incongruence between natal sex (sex assigned at birth) and gender identity. Gender queer is a label sometimes used by people whose gender identity does not fit the established categories of male or female. Natal sex describes the gender a person is born with or is assigned to at birth. Transgender is an adjective to describe a person who crosses or transcends culturally defined categories of gender. Transition is the period of time when transgender individuals change from the gender role associated with their sex to a different gender role.

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. Chemo gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers

ANS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Finish the prescribed antibiotic even if you are feeling better. b. Drink at least 3 liters of fluid each day. c. The bruising on your back may take several weeks to resolve. d. Report any blood present in your urine. e. It is normal to experience pain and difficulty urinating.

ANS: A, B, C The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

A primary care clinic sees some clients with sexually transmitted infections. Which diseases would the nurse be required to report to the local authority? (Select all that apply.) a. Chlamydia b. Gonorrhea c. Syphilis d. Human immune deficiency virus e. Pelvic inflammatory disease f. Human papilloma virus

ANS: A, B, C, D Chlamydia, gonorrhea, syphilis, human immune deficiency virus (HIV), and acquired immune deficiency syndrome (AIDS) are all reportable to local authorities in every state. Pelvic inflammatory disease and HPV do not need to be reported.

The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.) a. Wound infections b. Urethral complications c. Rectal injury d. Bleeding e. Donor site scarring f. Recurrent urinary tract infections

ANS: A, B, C, D, E Complications from phalloplasty include wound infections, urethral complications, rectal injuries, bleeding, and donor site scarring. Recurrent urinary tract infections are not a typical complication.

A client has pelvic inflammatory disease (PID). What complications does the nurse monitor the client for? (Select all that apply.) a. Chronic pelvic pain b. Infertility c. Ectopic pregnancy d. Tubo-ovarian abscess e. Peri-hepatitis f. Pancreatitis

ANS: A, B, C, D, E Possible complications of PID include chronic pelvic pain, infertility, ectopic pregnancy, tubo-ovarian abscess, peri-hepatitis, inflammation of the liver capsule, and inflammation of the peritoneal surfaces of the anterior right upper quadrant.

The nurse is assessing a client with acute pyelonephritis. What assessment findings would the nurse expect? (Select all that apply.) a. Fever b. Chills c. Tachycardia d. Tachypnea e. Flank or back pain f. Fatigue

ANS: A, B, C, D, E, F All of these assessment findings commonly occur in clients who have acute pyelonephritis because this health problem is a kidney infection.

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits f. Increased risk of bone fractures

ANS: A, B, C, D, E, F The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

A nurse works with many transgender clients. What routine monitoring is important for the nurse to facilitate in this population? (Select all that apply.) a. Lipid profile b. Liver function tests c. Mammograms if breast tissue is present d. Prostate-specific antigen (PSA) for natal males e. Renal profile f. Cervical cancer screening

ANS: A, B, C, D, F Common routine monitoring for this population includes lipid and liver panels, mammograms if any breast tissue is present, and PSA for natal males as the prostate is not removed during a vaginoplasty/penectomy. Cervical cancer screening is needed if the client has not had a total hysterectomy with a BSO. Renal profiles are not required based on treatment options for this population.

A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.) a. Recent prostatectomy b. Long-term hypertension c. Diabetes mellitus d. Hour-long exercise sessions e. Consumption of beer each night

ANS: A, B, C, E Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.

Which risk factors would the nurse teach a 23-year-old client about to prevent pelvic inflammatory disease (PID)? (Select all that apply.) a. Having multiple sexual partners b. Using an intrauterine device (IUD) c. Smoking d. Drinking two alcoholic beverages per day e. Having a history of sexually transmitted diseases (STDs)

ANS: A, B, C, E Some of the same factors that place women at risk for STDs also place women at risk for PID: sexually active women of age younger than 26 years, multiple sexual partners, use of an IUD, smoking, and a history of STDs. Alcohol consumption does not impact a womans risk for PID.

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness

ANS: A, B, C, E, F Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness.

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria

ANS: A, B, C, F Fever and chills may occur in clients who have a UTI if the infection has expanded beyond the bladder into the kidneys. However, these symptoms are not urinary signs and symptoms.

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Face mask c. Impervious gown d. N95 respirator e. Shoe covers f. Eye protection

ANS: A, B, C, F The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or "chemo" gloves), eye protection, a face mask, and a gown. An N95 respirator and shoe covers are not required.

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) a. Stress incontinence—urine loss with physical exertion b. Urge incontinence—loss of urine upon feeling the need to void c. Functional incontinence—urine loss results from abnormal detrusor contractions d. Overflow incontinence—constant dribbling of urine e. Reflex incontinence—leakage of urine without lower urinary tract disorder

ANS: A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. c. Adjust your diet to prevent diarrhea. d. Contact your provider if you have visual disturbances. e. Assess your urine for renal stones.

ANS: A, B, D A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the clients shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.

ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care

The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.) a. Infection of donor site b. Necrosis of the neopenis c. Rectal perforation d. Urinary tract stenosis e. Vaginal infections

ANS: A, B, D Complications from phalloplasty include infection or scarring of the donor site, necrosis, and stenosis of the urinary tract. Rectal perforation can occur with vaginoplasty, as can infections.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. How much water do you drink every day? b. Do you take estrogen replacement therapy? c. Does anyone in your family have a history of cystitis? d. Are you on steroids or other immune-suppressing drugs? e. Do you drink grapefruit juice or orange juice daily?

ANS: A, B, D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness

ANS: A, B, D Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence Urine loss with physical exertion b. Urge incontinence Large amount of urine with each occurrence c. Functional incontinence Urine loss results from abnormal detrusor contractions d. Overflow incontinence Constant dribbling of urine e. Reflex incontinence Leakage of urine without lower urinary tract disorder

ANS: A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

The nurse is teaching a client who is taking an oral antibiotic for treatment of a sexually transmitted disease (STD). Which statements by the client indicate a correct understanding of the treatment? (Select all that apply.) a. I need to drink at least 8 glasses of fluid each day with my antibiotic. b. I should read the instructions to see if I can take the medication with food. c. Antacids should not interfere with the effectiveness of the antibiotic. d. I need to wait 7 days after the last dose of the antibiotic to engage in intercourse. e. It should not matter if I skip a couple of doses of the antibiotic.

ANS: A, B, D When a client is being treated with an oral antibiotic for an STD, 8 to 10 glasses of fluid should be routine, medication instructions should be reviewed, and at least a week break should occur between the last dose of the antibiotic and sexual intercourse to allow for the medications full effects. Use of antacids and missing doses could decrease the effectiveness of the antibiotic.

A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a female client diagnosed with both diseases. Which items should be included in the clients teaching plan? (Select all that apply.) a. Expedited partner therapy b. Abstinence until therapy is completed c. Use of internal uterine devices d. Proper use of condoms e. Re-screening for infection f. Use of oral contraception

ANS: A, B, D, E As part of client/partner education, the nurse should explain the expedited partner therapy (practice of treating both sexual partners by providing medication to the client for the partner). The nurse should also emphasize the need for abstinence from sexual intercourse until treatment is finished, proper use of condoms, and rescreening for re-infection 3 to 12 months after treatment. The use of an intrauterine device and oral contraception is not part of the plan.

The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment

ANS: A, B, D, E In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.

A client has mucositis. What actions by the nurse will improve the clients nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal.

ANS: A, B, D, E Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids would be painful for the client

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.) a. Red rash b. Shortness of breath c. Heart irregularity d. Chest tightness e. Anxiety

ANS: A, B, D, E The nurse should keep all clients at the office for at least 30 minutes after the administration of benzathine penicillin G. Allergic manifestations consist of rash, shortness of breath, chest tightness, and anxiety, depicting anaphylaxis and serum sickness. Heart irregularity is not seen as an allergic manifestation.

The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus (SLE). Which of the following would be consistent with this disorder? (Select all that apply.) a. Discoid rash on skin exposed to sunlight b. Urinalysis positive for casts and protein c. Painful, deformed small joints d. Pain on inspiration e. Thrombocytosis f. Serum positive for antinuclear antibodies (ANA)

ANS: A, B, D, F Signs and symptoms of SLE include (but are not limited to) a discoid rash on skin exposed to the sun, urinalysis with casts and protein, pleurisy as manifested by pain on inspiration, and positive ANA titers in the blood. Nonerosive arthritis in peripheral joints can occur but does not lead to deformity. Thrombocytopenia is another sign

A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.) a. Wear a gown when contact of clothing with body fluids is anticipated. b. Teach clients and visitors respiratory hygiene techniques. c. Obtain powered air purifying respirators for all staff members. d. Do not use alcohol-based hand rub between client contacts. e. Disinfect frequently touched surfaces in client-care areas.

ANS: A, B, E Infection control measures appropriate to all clients include hand hygiene with alcohol-based hand rub or soap between client contact, procedures for routine care, cleaning and disinfection of frequently contaminated surfaces, and wearing personal protective equipment when contamination is anticipated. Client and visitors would be instructed on appropriate respiratory hygiene and cough etiquette. No information in the stem indicates the clients need anything more than Standard Precautions.

The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.) a. Assessing for blood pressure changes when lying, sitting, and arising from the bed b. Immediately reporting any change in the alanine aminotransferase laboratory test c. Teaching the client about the possibility of increased libido with these medications d. Taking the clients pulse rate for a minute in anticipation of bradycardia e. Asking the client to report any weakness, light-headedness, or dizziness

ANS: A, B, E Both the 5-alpha-reductase inhibitor (5-ARI) and the alpha1 -selective blocking agents can cause orthostatic (postural) hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause a decreased libido rather than an increased sexual drive. The alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.

A client has recurrent vulvovaginitis. Which statements by the client indicate a need for further teaching? (Select all that apply.) a. "I can take a long, hot bath to relieve itching." b. "I need to take all of my antibiotics as prescribed." c. "I should avoid having sex until my infection is gone." d. "I should not douche or use feminine hygiene sprays." e. "I should use antibacterial soap to clean the area." f. "I should switch to wearing only cotton underwear."

ANS: A, B, E Clients should avoid hot water baths as they may increase the itching and infection. They may take warm or tepid sitz baths for 30 minutes several times a day to relieve itching. Clients should cleanse the inner labia mucosa with water, not soap, during a bath or shower. All of the other options are correct. I think B isn't an answer?

A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this clients dietary teaching? (Select all that apply.) a. Limit your intake of food high in animal protein. b. Read food labels to help minimize your sodium intake. c. Avoid spinach, black tea, and rhubarb. d. Drink white wine or beer instead of red wine. e. Reduce your intake of milk and other dairy products.

ANS: A, B, E Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

ANS: A, B, E The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10, and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The client should begin to notice improvement in control of urine after several weeks of exercising the pelvic muscles.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors f. Early menarche

ANS: A, B, E, F Risk factors for breast cancer include advancing age, family and genetic history, early menarche, late menopause, postmenopausal obesity, physical inactivity, combined hormonal therapies, alcohol consumption, and lack of breast feeding.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care.

ANS: A, C A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.

A postmenopausal client is experiencing low back and pelvic pain, fatigue, and bloody vaginal discharge. What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected? (Select all that apply.) a. Cancer antigen-125 (CA-125) b. White blood cell (WBC) count c. Hemoglobin and hematocrit (H&H) d. International normalized ratio (INR) e. Prothrombin time (PT)

ANS: A, C Serum tumor markers such as CA-125 assess for metastasis, especially if elevated. H&H would evaluate the possibility of anemia, a common finding with postmenopausal bleeding with endometrial cancer. WBC count is not indicated since there are no signs of infection. The INR and PT are coagulation tests to measure the time it takes for a fibrin clot to form. They are used to evaluate the extrinsic pathway of coagulation in clients receiving oral warfarin.

A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.

ANS: A, C The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

The nurse is reviewing the results of a client's urinalysis. The client has a diagnosis of acute glomerulonephritis. Which urine findings would the nurse expect? (Select all that apply.) a. Presence of protein b. Presence of red blood cells c. Presence of white blood cells d. Acidic urine e. Dilute urine

ANS: A, C, D The nurse would expect all of these findings except that the urine is usually concentrated with a high specific gravity

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

ANS: A, C, D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

ANS: A, C, D, E Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.

A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) a. Diuretic therapy b. Anorexia nervosa c. Stroke d. Dementia e. Arthritis f. Parkinson disease

ANS: A, C, D, E, F Drugs, such as diuretics, cause frequent voiding, often in large amounts. Diseases or disorders that limit mobility, such as stroke, arthritis, and Parkinson disease, can prevent an individual from getting to the bathroom in a timely manner. Mental/behavioral problems, such as dementia, impair cognition and the ability to recognize when he or she needs to void.

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply approved moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. e. Teach the client to avoid sunlight. f. Make sure no clothing is rubbing the site.

ANS: A, C, D, F The nurse can delegate applying moisturizer approved by the radiation oncologist using mild soap for bathing, and helping the client pat wet skin dry after bathing. Any clothing worn over the site should be soft and not create friction. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.) a. Peau dorange b. Dense breast tissue c. Nipple retraction d. Mobile mass at two oclock e. Nontender axillary nodes f. Skin ulceration

ANS: A, C, D, F In the documentation of a breast mass, skin changes such as dimpling (peau d'orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the "face of a clock." Skin ulceration is also a common sign. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

A 28-year-old client is diagnosed with uterine leiomyoma and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Teach nonpharmacologic comfort measures. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Review complete blood count for possible iron deficiency anemia.

ANS: A, C, E With uterine leiomyomas or fibroids, heavy bleeding is the predominant symptom, with anxiety occurring because of fears of cancer or infertility. Interventions would be directed to the heavy bleeding and anxiety relief, such as relaxation techniques and education about the pathophysiology and possible treatment of the fibroids. While many women do not experience pain with this condition, some do, so the nurse would teach nonpharmacologic comfort measures. The nurse could suggest resources to give more information about the diagnosis. Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature and may increase the anxiety.

A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Reduce the pain by low-level heat. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Suggest resources such as the Endometriosis Association.

ANS: A, C, E With endometriosis, pain is the predominant symptom, with anxiety occurring because of the diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat, relaxation techniques, and education about the pathophysiology and possible treatment of endometriosis. The nurse could suggest resources to give more information about the diagnosis. Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature and may increase the anxiety.

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash your hands before and after self-catheterization. b. Use a large-lumen catheter for each catheterization. c. Use lubricant on the tip of the catheter before insertion. d. Self-catheterize at least twice a day or every 12 hours. e. Use sterile gloves and sterile technique for the procedure. f. Maintain a specific schedule for catheterization.

ANS: A, C, F The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

The nurse is planning health teaching for a client starting mirabegron for urinary incontinence. What health teaching would the nurse include? (Select all that apply.) a. "Monitor blood tests carefully if you are prescribed warfarin." b. "Avoid crowds and individuals with infection." c. "Report any fever to your primary health care provider." d. "Take your blood pressure frequently at home." e. "Report palpitations or chest soreness that may occur."

ANS: A, D This drug can cause increase blood pressure and, therefore, the client's blood pressure should be monitored. Mirabegron can increase the effect of warfarin causing bleeding or bruising. The client will need additional coagulation studies to ensure that the INR is within a therapeutic range.

A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? (Select all that apply.) a. Observe the client for at least 2 hours afterward. b. Instruct the client about the monthly infusion schedule. c. Inform the client not to drive or sign legal papers for 24 hours. d. Ensure emergency equipment is working and nearby. e. Make a follow-up appointment for a lipid panel in 2 months. f. Instruct the client to hold other medications for 72 hours.

ANS: A, D This drug is a monoclonal antibody to tumor necrosis factor. The first dose would be administered in a place where severe allergic reactions and/or anaphylaxis can be managed. This includes having emergency equipment nearby. The client would be observed for at least 2 hours after this first dose. This drug does not cause drowsiness, so there would be no restrictions on driving or signing legal documents. Elevated lipids are not associated with this drug. This drug is used in combination with other therapies, especially during a flare.

A woman is interested in alternative and complementary treatments for the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which therapies wound the nurse suggest? (Select all that apply.) a. Acupuncture b. Chiropractic c. Journaling d. Aromatherapy e. Shiatsu f. Black cohosh

ANS: A, D, E Alternative and complementary measures are chosen by many women. For nausea and vomiting, the best choices would be acupuncture, aromatherapy, and shiatsu. Chiropractic treatments would help pain. Journaling would be beneficial for fear and anxiety. Black cohosh is frequently used for hot flashes

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination

ANS: A, D, E Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast selfawareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue.

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. Family history of prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race

ANS: A, D, E, F Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors.

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

ANS: A, E Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, not douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton underwear is best.

A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material? a. "I will avoid direct sunlight as much as possible." b. "Baby powder is good for the constant sweating." c. "Grouping errands will help prevent fatigue." d. "Rest time will have to become a priority."

ANS: B Constant sweating is not a sign of SLE and powders are drying so they should not be used, at least not in excess. The client is correct in stating he/she should avoid direct sunlight, that grouping errands can prevent or reduce fatigue, and that rest will have to become a priority

A nurse is caring for a woman who had hysteroscopic surgery for uterine leiomyomas. On initial assessment, the nurse notes the following: pulse: 114 beats/min, respiratory rate: 20 breaths/minute, crackles in bilateral lung bases. What action by the nurse takes priority? a. Assess the client for pain. b. Call the Rapid Response Team. c. Obtain an oxygen saturation. d. Delegate a temperature.

ANS: B The fluid that is used during this procedure to distend the uterine cavity can be absorbed, leading to fluid overload. This client has signs of fluid overload which can be critical. The nurse would notify the Rapid Response Team first, then perform the other actions

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Show the family how to avoid spreading the disease. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

ANS: B Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors that taking appropriate precautions will minimize their risks. The nurse would then demonstrate what precautions were needed. The other options do nothing to ease the family's fears.

A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important? a. Assess the client for a headache or dizziness. b. Request a prescription for cardiac monitoring c. Instruct the client to change positions slowly. d. Weigh the client daily before eating.

ANS: B 5-HT3 antagonists, such as ondansetron, can prolong the QT interval within the cardiac conduction cycle. ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), heart failure, bradyarrhythmias or patients taking other medications that can cause QT prolongation. The nurse would contact the primary health care provider and request cardiac monitoring. The nurse would assess the client for any other reported changes, but this is not a critical safety factor. Weight is not related directly to this drug.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

ANS: B A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective isolation precautions.

ANS: B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs

ANS: B A humidifier will help relieve many of the clients Sjgrens syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation

ANS: B A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.

A new nurse care for several client after radical prostatectomies for prostate cancer. What action by the nurse indicates a need to review care measures for this type of client? a. Delegates emptying and recording contents of the drainage devices. b. Administers a suppository to the client who reports constipation. c. Removes the sequential compression stockings on ambulatory clients. d. Discusses long-term complications such as erectile dysfunction.

ANS: B After a radical prostatectomy, the nurse would not provide a rectal suppository for constipation. All rectal treatments are contraindicated. The nurse would delegate emptying and recording drainage, remove the sequential pressure devices when clients begin ambulating, and discuss long-term complications of the operation.

The nurse has provided postvasectomy discharge instructions to the client. What statement by the client demonstrates good understanding? a. "We can have unprotected intercourse as soon as I have healed." b. "An ice pack to my scrotum will help with the swelling." c. "I need to report signs of infection, swelling, or bruising right away." d. "The stitches can be removed here in the office in 7 to 10 days."

ANS: B After vasectomy, clients are instructed to use birth control until the 3-month semen analysis shows that the procedure has worked, to use an ice pack intermittently for 24 to 48 hours, that swelling and bruising are normal, and the bandage can be removed in 48 hours. There are no sutures to be removed.

A nurse provides health screening for a community health center with a large population of African American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.

ANS: B All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the clients urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

ANS: B An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight

ANS: B Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

The nurse is administering sulfamethoxazole-trimethoprim (Bactrim) to a client diagnosed with bacterial prostatitis. Which finding causes the nurse to question this medication for this client? a. Urinary tract infection b. Allergy to sulfa medications c. Hematuria d. Elevated serum white blood cells

ANS: B Before administering sulfamethoxazole-trimethoprim, the nurse must assess if the client is allergic to sulfa drugs. Urinary tract infection, hematuria, and elevated serum white blood cells are common problems associated with bacterial prostatitis that require long-term antibiotic therapy.

A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at this time? a. Have you been using latex condoms? b. Are you allergic to penicillin? c. When was your last sexual encounter? d. Do you have a history of sexually transmitted disease?

ANS: B Benzathine penicillin G is the evidence-based treatment for primary syphilis. The client needs to be assessed for allergies before treatment. The other questions would be helpful in the clients history of sexually transmitted diseases but not as important as knowing whether the client is allergic to penicillin.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Five hours after the operation, the nurse notes the drainage is bright red with clots. What action should the nurse take first? a. Review the most recent hemoglobin and hematocrit. b. Take vital signs and begin immediate irrigation with sterile water. c. Notify the primary health care provider immediately. d. Remind the client not to pull on the catheter.

ANS: B Bright red urinary drainage with clots may indicate arterial bleeding. The nurse would notify the primary health care provider immediately and begin irritating the catheter with sterile normal saline (not sterile water). The nurse can delegate the vital signs. The nurse would review hemoglobin and hematocrit and would remind the client not to pull on the catheter for all clients with bladder irrigation. But for this client who may be bleeding the nurse would take further action to address the problem.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? a. Review the hemoglobin and hematocrit as ordered. b. Take vital signs and notify the surgeon immediately. c. Release the traction on the three-way catheter. d. Remind the client not to pull on the catheter.

ANS: B Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take a laxative every night before going to bed. b. I must increase my intake of dietary fiber and fluids. c. I shall only use salt when I am cooking my own food. d. Ill eat white bread to minimize gastrointestinal gas.

ANS: B Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a highfiber diet.

An emergency department nurse assesses a client with kidney trauma and notes that the clients abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products

ANS: B Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the clients vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Assessing skin and mucous membranes b. Consistently using appropriate hand hygiene c. Monitoring daily white blood cell counts d. Teaching visitors not to visit if they are ill

ANS: B Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare associated infections are due to staff members contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.

A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate? a. You are too old to receive an HPV vaccine. b. Either Gardasil or Cervarix can provide protection. c. You will need to have three injections over a span of 1 year. d. The most common side effect of the vaccine is itching at the injection site.

ANS: B Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is recommended that young women up to 26 years should receive an HPV vaccine. The entire series consists of three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very common, but this does not include itching.

A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important? a. Ensure that the urinary catheter is securely attached to the leg. b. Instruct the client not to try to get out of bed unassisted. c. Monitor the clients dressings and wound drainage. d. Position the Jackson-Pratt drain to the contralateral side.

ANS: B Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important for client safety that adequate help is available prior to this client trying to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation c. A 64-year-old female with Alzheimers-type senile dementia Bladder training d. A 77-year-old female who has difficulty ambulating Exercise therapy

ANS: B Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Physical therapy and a bedside commode would be appropriate interventions for the client who has difficulty ambulating. Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate.

A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

ANS: B Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.

A client with cancer has anorexia and mucositis, and is losing weight. The clients family members continually bring favorite foods to the client and are distressed when the client wont eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isn't able to eat now no matter what they bring.

ANS: B Families often become distressed when their loved ones wont eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

A client with metastatic prostate cancer has been prescribed leuprolide, a bisphosphonate, and flutamide. Which statement by the client warrants further investigation by the nurse? a. "I go for a short walk each day, even when I am very tired." b. "My wife has noticed my eyes looking a little yellow." c. "I ordered some looser shirts to hide my enlarging breasts." d. "Now I understand my wife's hot flashes with menopause."

ANS: B Flutamide is an antiandrogen drug that can cause liver toxicity. The nurse would follow up on the statement that the client's eyes may be looking a little yellow which could indicate the onset of this adverse effect. Leuprolide can cause osteoporosis, hot flashes, and gynecomastia. The statements regarding weight-bearing exercise, enlarging breasts, and hot flashes are not cause for concern.

A 19-year-old college student seeks information from the schools nurse about how to avoid sexually transmitted diseases (STDs) without abstinence as a choice. Which statement by the nurse is best? a. Urinating after intercourse will eliminate the risk of infection. b. A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV). c. Oral contraception can prevent pregnancy and STDs. d. Good handwashing helps prevent infection associated with STDs.

ANS: B Gardasil is used to provide immunity for HPV types 6, 11, 16, and 18 that are high risk for cervical cancer and genital warts. While there is some truth that urination after intercourse may decrease the risk of infection by flushing out organisms, it does not eliminate the risk of contaminating bacteria traveling up the urethra. The other statements are not accurate.

The nurse is teaching a transgender client about the medication goserelin (Zoladex). What action by the client indicates good understanding? a. Takes a manual blood pressure b. Administers a subcutaneous injection c. Prepares an implanted port for IV insertion d. States that the axillary area will be clothed

ANS: B Goserelin is administered via subcutaneous injection. The other actions are not related to self-management while on this medication.

After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAPs understanding. Which action indicates the UAP needs additional teaching? a. Toileting the client after breakfast T b. Changing the clients incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the clients incontinence episodes

ANS: B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.

ANS: B In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? a. You do not need to worry about lymphedema since you did not have radiation therapy. b. A risk factor for lymphedema is infection, so wear gloves when gardening outside. c. Numbness, tingling, and swelling are common sensations after a mastectomy. d. The risk for lymphedema is a real threat and can be very self-limiting.

ANS: B Infection can create lymphedema; therefore, the client needs to be cautious with activities using the affected arm, such as gardening. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and the presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives.

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? a. "You do not need to worry about lymphedema since you did not have radiation therapy." b. "Be careful not to injure that arm or get any infection in that arm." c. "Numbness, tingling, and swelling are common sensations after a mastectomy." d. "The risk for lymphedema is a real threat and can be very self-limiting."

ANS: B Injury and infection are risk factors for lymphedema; therefore, the client needs to be cautious with activities using the affected arm. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area. d. It is likely that you have an untreated sexually transmitted disease.

ANS: B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

A client is preparing for gender reassignment surgery and will transition from male to female. The client is worried about the voice not sounding feminine enough. What action by the nurse is best? a. Ask if the client has considered vocal cord surgery to change the voice. b. Refer the client for vocal therapy with speech-language pathology. c. Teach the client that there will be no effect on the clients voice. d. Tell the client that the use of hormones will eventually change the voice.

ANS: B Male-to-female clients can consult with a speech-language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client there will be no change to the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.

After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today

ANS: B Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.

A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? a. Assess the client for a headache. b. Assist the client in getting out of bed. c. Instruct the client to reduce salt intake. d. Weigh the client daily before the client eats.

ANS: B Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the clients risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen

ANS: B Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

The nurse is doing preoperative teaching for a client who is scheduled for removal of cervical polyps in the office. Which statement by the client indicates a correct understanding of the procedure? a. I hope that I do not have cancer of the cervix. b. There should be little or no discomfort during the procedure. c. There may be a lot of bleeding after the polyp is removed. d. This may prevent me from having any more children.

ANS: B Polyp removal is a simple office procedure with the client feeling no pain. The other responses are incorrect. Cervical polyps are the most common benign growth of the cervix. Cautery is used to stop any bleeding, and there is no evidence that cervical polyps have a relationship to childbearing.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. Are you getting adequate rest and sleep each day? b. It is normal to be fatigued even for years afterward. c. This is not normal and Ill let the provider know. d. Try adding more vitamins B and C to your diet.

ANS: B Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is normal.

An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first? a. Are you drinking plenty of water? b. What medications are you taking? c. Have you tried laxatives or enemas? d. Has this type of thing ever happened before?

ANS: B Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the clients medication list to determine whether the client is taking an anticholinergic medication. If he or she is taking anticholinergics, the nurse should further assess the clients manifestations to determine if they are related to a simple side effect or an overdose. The other questions are not as helpful to understanding the current situation.

A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer? a. The cancer has spread to the mucosa of the bowel and bladder. b. It has reached the vagina or lymph nodes. c. The cancer now involves the cervix. d. It is contained in the endometrium of the cervix.

ANS: B Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium. Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.

After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take this medication with food and plenty of water. b. I shall keep my appointment at the infusion center each week. c. Ill limit my intake of green leafy vegetables while on this medication. d. I must not take this medication if I have an infection or am feeling ill.

ANS: B Temsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet.

The nurse is teaching a transgender client about taking testosterone. What statement by the client indicates good understanding? a. "My periods should stop immediately." b. "Some effects can take up to a year to see." c. "I am glad I don't have to watch my diet." d. "There are very few side effects since it's a normal hormone."

ANS: B Testosterone is used as masculinizing drug therapy. Some desired effects may take up to a year to be noticed. Menses should stop within the first few months of therapy. Testosterone increases the risk of heart disease, so clients should follow a heart-healthy diet. Testosterone has several side effects, including acne, seborrhea, weight gain, edema, headaches, and possible psychosis.

After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I can prevent more damage to my kidneys by managing my blood pressure. b. If I have increased urination at night, I need to drink less fluid during the day. c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.

ANS: B The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this clients teaching? a. Use the toilet when you first feel the urge, rather than at specific intervals. b. Try to consciously hold your urine until the scheduled toileting time. c. Initially try to use the toilet at least every half hour for the first 24 hours. d. The toileting interval can be increased once you have been continent for a week.

ANS: B The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL d. White blood cell count: 12,000/mm3

ANS: B The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is the most appropriate? a. Breast cancer in men is quite rare. b. It is good that you came to be carefully evaluated. c. Gynecomastia usually comes from overeating. d. When you get older, the male breast always enlarges.

ANS: B The most appropriate statement is the one that is supportive of the client. A breast mass should be carefully evaluated for breast cancer, even if it is not common. Gynecomastia as a symptom can be related to antiandrogen agents, aging, obesity, estrogen excess, or lack of androgens.

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

ANS: B The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

An African-American female with blisters on the vagina is being treated with acyclovir (Zovirax) for genital herpes. She is angry at her partner for transmitting the infection. Which action by the nurse is best? a. Encourage the client to engage in sexual activity since she is on medication. b. Be sensitive to the clients feelings and refer her to a support group. c. Reinforce that the disease can no longer be spread to other partners. d. Reassure the client that sexual activity will not be painful while on acyclovir.

ANS: B The nurse needs to be sensitive and supportive of the client since infected clients may feel angry, lonely, and isolated. Allow the client to verbalize her feelings and refer her to a local support group, such as the National Herpes Resource Center. Sexual activity should not occur while the lesions are present because of discomfort and viral transmission. Genital herpes is an incurable viral disease, and the antiviral drugs minimize the infection but do not cure it. Condoms should be used to avoid the spread of the disease.

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium 128 mEq/L Hemoglobin 14 g/dL Hematocrit 42% Red blood cell count 4.5 What action by the nurse is the most appropriate? a. Consider starting a blood transfusion. b. Slow down the bladder irrigation if the urine is pink. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

ANS: B The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.

A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the clients right lower back. Which action should the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

ANS: B The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the clients position will not decrease bleeding.

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. Avoid getting salt water on the radiation site. b. Do not expose the radiation area to direct sunlight. c. Have a wonderful time and enjoy your vacation! d. Remember you should not drink alcohol for a year.

ANS: B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important? a. Administer IV fluids to maintain fluid and electrolyte balance. b. Remove the tampon as the source of infection. c. Collect a blood specimen for culture and sensitivity. d. Transfuse the client to manage low blood count.

ANS: B The source of infection should be removed first. All of the other answers are possible interventions depending on the clients symptoms and vital signs, but removing the tampon is the priority.

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by nurse is best? a. Take the clients vital signs and record them in the chart. b. Notify the surgeon about the aspirin ingestion by the client. c. Warn the client that health insurance may not pay for the procedure. d. Teach the client about avoiding twisting above the waist after the operation.

ANS: B The surgeon must be notified immediately since the aspirin could cause increased bleeding during the procedure. Vital signs should be recorded and postoperative teaching should be completed in the preoperative time frame, but these are not the priority since the procedure may be rescheduled. The warning about the clients health insurance is not appropriate at this time.

A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? a. Obtain cultures of the lesions. b. Place the client on Airborne Precautions. c. Prepare to administer antibiotics. d. Provide comfort measures for the rash.

ANS: B This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.

A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important? a. Assessing the clients abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the clients bilateral pedal pulses d. Reviewing client teaching done previously

ANS: B This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.

A client has recently been diagnosed with type II endometrial cancer and will be treated with brachytherapy. What statement by the client indicates a need for further education on this treatment? a. "Each treatment will take only 20 to 30 minutes." b. "I have to be alone in the room during treatment so I don't expose others." c. "I can get up and walk around or read in a chair during the treatments." d. "I need to report any heavy vaginal bleeding or severe diarrhea."

ANS: B Type II endometrial cancer is likely to invade the uterine wall and metastasize. Treatment with brachytherapy is intended to prevent recurrence. During the treatment, which lasts 20 to 30 minutes each, the woman must remain on bedrest to avoid dislodging the radioactive source. The source emits radiation while it is in place, so the woman is in the treatment room by herself. Once it is removed, she has no restrictions on being around others. She would need to report any heavy vaginal bleeding or severe diarrhea.

The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir

ANS: B, C, D, E Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

ANS: B, C, D, E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature

The nurse is teaching a client about side effects and adverse reactions of a PDE5 inhibitor. What information does the nurse include? (Select all that apply.) a. Refrain from eating citrus fruit within 24 hours of taking the medication. b. Stop using this drug if your primary health care provider prescribes a nitrate. c. Do not drink alcohol before having sexual intercourse. d. Muscle cramps, nausea, and vomiting are possible if you take more than 1 pill a day. e. Take this medication within 30 to 60 minutes of having sexual intercourse. f. Change positions slowly especially if you also take an anti-hypertensive drug.

ANS: B, C, D, F A PDE5 inhibitor is used to treat erectile dysfunction. The client should avoid grapefruit or grapefruit juice while taking these drugs. Taking a PDE5 inhibitor along with a nitrate can cause a profound drop in blood pressure. Alcohol may interfere with the ability to have an erection. Muscle cramps, nausea, and vomiting are possible side effects if more than 1 pill a day are taken. Each medication has its own directions for how soon to take it before intercourse, from 15 minutes to 2 hours. Any PDE5 drug can lower blood pressure so the nurse alerts the client of safety precautions.

A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.) a. You will need to be hospitalized during this therapy. b. Your skin needs to be inspected daily for any breakdown. c. It is not wise to stay out in the sun for long periods of time. d. The perineal area may become damaged with the radiation. e. The technician applies new site markings before each treatment. f. You will not be radioactive or pose any danger to anyone else.

ANS: B, C, D, F EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The technician does not apply new site markings, so the client needs to avoid washing off the markings that indicate the treatment site.

A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.) a. Administer prophylactic antibiotics. b. Monitor white blood cell count and differential. c. Screen all visitors for infections. d. Implement Transmission-Based Precautions. e. Promote sufficient nutritional intake.

ANS: B, C, E Nursing interventions for clients at risk for infection include monitoring white blood cell count and differential, screening visitors for infections and infectious disease, and promoting sufficient nutritional intake. Standard Precautions are required but not Transmission-Based Precautions. Prophylactic antibiotics are not generally used to prevent infections.

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea

ANS: B, C, E Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

The nurse is doing home care teaching for a client who has undergone cryotherapy. Which statements by the client indicate a correct understanding of the instructions? (Select all that apply.) a. "I can resume my weight-lifting exercise class tomorrow." b. "I should not use tampons, douche, or have sexual activity." c. "I should shower rather than take a tub bath." d. "There may be a lot of bleeding for a few days." e. "There should be little or no discomfort."

ANS: B, C, E Cryotherapy involves freezing of cervical cancer cells and is often painless. Clients are restricted from heavy lifting. They may have a heavy watery discharge for several weeks, but should report any heavy bleeding, foul-smelling drainage, or a fever. The other options are correct.

A client with an infection has a fever. What actions by the nurse help increase the clients comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the clients gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client f. Sponging the client with tepid water.

ANS: B, C, F Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics will be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes. Sponging the client's body with tepid water is also helpful.

A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.) a. Infection b. Cardiovascular impairment c. Vasculitis d. Chronic kidney disease e. Liver failure f. Blood dyscrasias

ANS: B, D Any and all organs and tissues may be affected in SLE but the most common causes of death in clients with SLE include cardiovascular impairment and chronic kidney disease.

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

ANS: B, D, E After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

ANS: B, E Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

ANS: B, E Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the evening hours.

A client with genital herpes has painful blisters on her vulva. After teaching the client self-care measures, which statement indicates the need for further education? a. "Pouring water over my genitals will decrease the pain of urinating." b. "I will wash my hands carefully after applying ointment." c. "When I don't have lesions, I am not contagious to my sexual partner." d. "I should increase my fluid intake when I have open lesions."

ANS: C A client with genital herpes can still spread the disease when asymptomatic through viral shedding. The client is taught to use condoms with all sexual activity. Pouring water over the genitals (or urinating in the shower) will help decrease the pain of urine passing over open lesions. Good handwashing is important. Open lesions can lead to fluid loss so the client is taught to increase fluid intake

A nurse is providing education to a new 55-year-old African-American client about screening for prostate cancer. What action by the nurse is most appropriate? a. Inform the client that recommendations vary, so screening is a personal choice. b. Let the client know that as an African American, he should be screened annually. c. Teach the client that he is in a high risk group and should discuss screening. d. Give the client written information that discourages screening until age 70.

ANS: C Clients in certain high risk groups should discuss screening for prostate cancer with their primary health care providers at age 45. High risk groups include African Americans and men with a first-degree relative who was diagnosed with prostate cancer before the age of 65. This new client will be encouraged to discuss screening even though he is past the age of initial discussion. Recommendations do vary somewhat, but he is in a recognized high risk group. The nurse would not say that he "should" be screened annually. Screening is not recommended for men over the age of 70.

A nurse cares for a client who has pyelonephritis. The client states, I am embarrassed to talk about my symptoms. How should the nurse respond? a. I am a professional. Your symptoms will be kept in confidence. b. I understand. Elimination is a private topic and shouldnt be discussed. c. Take your time. It is okay to use words that are familiar to you. d. You seem anxious. Would you like a nurse of the same gender to care for you?

ANS: C Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the clients symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse? a. Not using gloves while combing the client's hair b. Rinsing the client's commode pan after use c. Ordering an oscillating fan for the client d. Wearing gloves when providing perianal care

ANS: C Fans in client care areas are discouraged because they can disperse airborne or droplet-borne pathogens. The other actions are appropriate. If the client has a scalp infection or infestation, the AP will wear gloves; otherwise, it is not required for grooming the hair

The nurse is working with a male client who has gynecomastia. What action by the nurse is most appropriate? a. Teach the client to perform self-breast examination. b. Review the plan for chemotherapy after surgery. c. Educate him on the side effects of tamoxifen. d. Assess his usual daily alcohol intake.

ANS: C Gynecomastia is enlarged breast tissue in men. It is from an enlarged ridge of glandular breast tissue and is benign. The client does not need to perform SBE nor will he undergo chemotherapy. Tamoxifen is one drug used to treat the condition, so the nurse would educate the client on the medication. Alcohol is not related.

The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? a. Urinary retention b. Urinary incontinence c. Painless hematuria d. Difficulty urinating

ANS: C The classic and most common finding in clients who have bladder cancer is painless and intermittent hematuria that can be with gross or microscopic. Dysuria, frequency, and urgency occur in clients who have bladder infection or obstruction

The nurse is caring for a client who has chronic pyelonephritis. What assessment finding would the nurse expect? a. Fever b. Flank pain c. Hypertension d. Nausea and vomiting

ANS: C The client who has chronic pyelonephritis has renal damage and therefore has hypertension. The other assessment findings commonly occur in clients with acute pyelonephritis

A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material? a. "I should take precautions against ticks, especially in the summer." b. "A red rash that looks like a bull's-eye may be one of the symptoms." c. "If Lyme disease is not treated successfully, it is usually fatal." d. "For Stage I disease, antibiotics are usually needed for 14 to 21 days."

ANS: C Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease, such as arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal disease so this information would need to be corrected by the nurse. The other participant statements are correct.

A client has a recurrent Bartholin cyst. What is the nurses priority action? a. Apply an ice pack to the area. b. Administer a prophylactic antibiotic. c. Obtain a fluid sample for laboratory analysis. d. Suggest moist heat such as a sitz bath.

ANS: C A major cause of an obstructed duct forming a cyst is infection. The laboratory specimen is a priority since a culture is needed in order to prescribe sensitive antibiotics. Comfort measures can then be used, such as ice packs and moist heat.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

ANS: C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider? a. Breast tenderness b. Headaches c. Red, swollen calf d. Swollen ankles

ANS: C A red, swollen calf could be a manifestation of a deep vein thrombosis, a known side effect of estrogen. The nurse reports this finding immediately. The other manifestations are also side effects of estrogen, but do not need to be reported as a priority.

A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a. Do you want daily weights on this client? b. Will the client be able to return home? c. Can we discontinue the indwelling catheter? d. Should we get another chest x-ray today?

ANS: C An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond? a. Test your urine daily for the presence of ketone bodies and proteins. b. Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.

ANS: C Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the clients sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

A 55-year-old post-menopausal woman is assessed by the nurse with a history of dyspareunia, backache, pelvis pressure, urinary tract infections, and a frequent urinary urgency. Which condition does the nurse suspect? a. Ovarian cyst b. Rectocele c. Cystocele d. Fibroid

ANS: C Dyspareunia, backache, pelvis pressure, urinary tract infections, and urinary urgency are all symptoms of a cystocelea protrusion of the bladder through the vaginal wall. Ovarian cysts are rare after menopause. A rectocele is associated with constipation, hemorrhoids, and fecal impaction. Fibroids are associated with heavy bleeding.

Before marriage, a female client has a blood test drawn for syphilis. The test reveals a positive Venereal Disease Research Laboratory (VDRL) serum test. What is the advice that the nurse should give the client? a. Check with your future husband about his sexual activity. b. You must determine if you are pregnant at this time. c. Submit to a more specific treponemal test to confirm the infection. d. Agree to a benzathine penicillin G injection in multiple doses.

ANS: C False-positive reactions can occur with viral infections, hepatitis, and systemic lupus erythematosus. A health care provider can request more specific treponemal tests such a fluorescent treponemal antibody absorption or microhemagglutination assay for Treponema palladium performed by the laboratory. While it would be good to confirm sexual activity with her future husband, this inquiry could wait until after further testing is performed. Penicillin is the treatment of choice, but as a single 2.4-million-unit dose. A different regimen would be recommended if the client were pregnant.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

ANS: C Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy

A 25-year-old woman is concerned about contracting HPV. What information by the nurse is most appropriate? a. "HPV is a benign infection that usually clears up on its own." b. "You are too old to receive the HPV vaccination." c. "We can provide HPV testing along with your Pap smear." d. "HPV is not a common sexually transmitted disease."

ANS: C HPV DNA testing can be done at the same time as the pap smear. Most women have HPV infection during their lives; however, it is not always benign. Two types, 16 and 18 are responsible for about 70% of cervical cancers. The vaccination with Gardasil 9 can be given up to age 45.

A client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The client reports headache and dizziness. What action by the nurse is most appropriate? a. Consider starting a blood transfusion. b. Slow the bladder irrigation down. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes

ANS: C Headache, dizziness, and shortness of breath are symptoms of possible TURP syndrome in which the irrigation fluid is absorbed, putting strain on the client's heart. The nurse notifies the primary health care provider immediately as the client may need intensive care monitoring. There is no data indicating the client needs a blood transfusion, plus that would add even more fluid in the system. The irrigant may need to be slowed but that is not the first action the nurse would take. Vital signs do need to be taken frequently in this situation, but the nurse notifies the primary health care provider first

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. Checking the amount of urine in the urine catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

ANS: C Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

ANS: C Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable masses throughout the breast tissue could be a fibrocystic breast condition. A firm, defined mobile mass in the lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local abscess or ductal ectasia

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each of my three children for 12 months. b. It looks as though I need to start working out at the gym more often. c. I am glad that we can still have wine with every evening meal. d. When I have menopausal symptoms, I must avoid hormone replacement therapy

ANS: C Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for breast cancer prevention

The nurse is providing preoperative education to a client prior to having an orchiectomy for testicular cancer. What statement by the client indicates the need to review the information? a. "I can still function sexually without one of my testes." b. "I will investigate sperm banking before the operation." c. "There should be no effect on my ability to reproduce." d. "Testicular self-exam will be important on the remaining testis."

ANS: C Oligospermia and azoospermia are common in clients with testicular function and can affect reproduction. The statement that there will be no effect on reproduction requires the nurse to review the information with the client. Sperm banking is an option prior to treatment to store sperm for future use. Normal sexual function is possible with one testis. Self-examination of the remaining testis is important for early detection of another tumor.

What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago? a. Placing the head of bed at 30 degrees b. Elevating the left arm on a pillow c. Administering morphine for pain at a 4 on a 0-to-10 scale d. Supporting the left arm while initially ambulating the client

ANS: C Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of pain by the client. The UAP could position the bed to 30 degrees and elevate the clients arm on a pillow to facilitate lymphatic fluid drainage return. The clients arm should be supported while walking at first but then allowed to hang straight by the side. The UAP could support the arm while walking the client.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice daily.

ANS: C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin? a. On a scale from 0 to 10, what is the rating of your chest pain? b. Are you allergic to any food or medications? c. Have you taken any drugs like Viagra recently? d. Are you light-headed or dizzy right now?

ANS: C Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.

A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

ANS: C Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? a. It causes rapid lysis of the cancer cell membranes. b. It destroys the enzymes needed to create cancer cells. c. It prevents the start of cell division in the cancer cells. d. It sensitizes certain cancer cells to chemotherapy.

ANS: C Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.

A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a clients bed linens. What action by the UAP requires intervention by the nurse? a. Not using gloves while combing the clients hair b. Rinsing the clients commode pan after use c. Shaking dirty linens and placing them on the floor d. Wearing gloves when providing perianal care

ANS: C Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.

A 25-year-old client has recently been diagnosed with testicular cancer and is scheduled for radiation therapy. Which intervention by the nurse is best? a. Ask the client about his support system of friends and relatives. b. Encourage the client to verbalize his fears about sexual performance. c. Explore with the client the possibility of sperm collection. d. Provide privacy to allow time for reflection about the treatment.

ANS: C Sperm collection is a viable option for a client diagnosed with testicular cancer and should be completed before radiation therapy, chemotherapy, or radical lymph node dissection. The other options would promote psychosocial support but are not the priority intervention.

A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority? a. Draw blood to test serum potassium. b. Have the client lie down. c. Obtain a STAT electrocardiogram (ECG). d. Take a set of vital signs.

ANS: C Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurses priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client lie down and obtaining vital signs are also important care measures, but do not take priority.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the clients serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.

ANS: C Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of mental illness is not an appropriate action.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first? a. Client with dry, itchy, peeling skin b. Client with a serum calcium of 9.2 mg/dL c. Client with a serum potassium of 2.8 mEq/L d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day

ANS: C TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells.

ANS: C Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide (Lupron) does this. Chemotherapy agents such as ixabepilone (Ixempra) interfere with cancer cell division, and doxorubicin (Adriamycin) inhibits DNA synthesis in susceptible cells.

A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. The nurse suspects syphilis. Which action by the nurse is appropriate? a. Reassure the client that this stage is not infectious unless she is pregnant. b. Assess the client for hearing loss and generalized weakness. c. Don gloves and further assess the clients lesions. d. Take a history regarding any cardiovascular symptoms.

ANS: C The client is displaying symptoms similar to secondary syphilis, with flu-like symptoms and rash due to the spirochetes circulating throughout the bloodstream. Therefore, the nurse needs to further assess the clients lesions with gloves since the client is highly contagious at this stage. Late latent syphilis is not infectious except to a fetus. Tertiary syphilis may display in the form of cardiovascular or central nervous system symptoms

A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0 to 10. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Administer Tylenol #3 immediately. b. Apply a heating pad to the lower abdomen. c. Position the client in a semi-Fowlers position. d. Teach the client to increase intake of fluids.

ANS: C The client with pelvic inflammatory disease usually experiences lower abdominal tenderness. The UAP can position the client. Only the nurse can administer medications, initially apply heat to the clients abdomen, and perform teaching.

The nurse is examining a woman's breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask? a. When was your last mammogram at the clinic? b. How many cans of caffeinated soda do you drink in a day? c. Do the small lumps seem to change with your menstrual period? d. Do you have a first-degree relative who has breast cancer?

ANS: C The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast conditions, but research has not found that it has a significant impact. Questions related to the clients last mammogram or breast cancer history are not related to the nurses assessment.

A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as George Smith. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best? a. Apologize and declare confusion about the client. b. Ask Mrs. Smith where her husband is right now. c. Ask the client about preferred forms of address. d. Explain that the chart must contain an error.

ANS: C The nurse may encounter transgender clients whose outward appearance does not match their demographic data. In this case, the nurse should greet the client and ask the client to explain his or her preferred forms of address. Lengthy apologies can often create embarrassment. The nurse should not assume the client is not present in the room. The chart may or may not contain errors, but that is not related to determining how the client prefers to be addressed.

A nurse cares for a client with urinary incontinence. The client states, I am so embarrassed. My bladder leaks like a young child's bladder. How should the nurse respond? a. I understand how you feel. I would be mortified. b. Incontinence pads will minimize leaks in public. c. I can teach you strategies to help control your incontinence. d. More women experience incontinence than you might think.

ANS: C The nurse should accept and acknowledge the clients concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the clients concerns with the use of pads or stating statistics about the occurrence of incontinence.

A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call light, the client presents an appearance as shown below: What action by the nurse takes priority? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these manifestations will go away

ANS: C The nurse should ensure the clients airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. Complete blood count b. Culture and sensitivity c. Prostate-specific antigen d. Cystoscopy

ANS: C The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.

A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection? a. I did practice abstinence while taking the medication. b. I took doxycycline two times a day for a week. c. I never told my boyfriend about the infection. d. I did drink wine when taking the medication for Chlamydia.

ANS: C There is a good possibility that the boyfriend re-infected the client after the medication regimen was finished. Both the client and the boyfriend need to be treated. The other statements were in compliance with the recommendations of abstinence and the usual medication regimen with doxycycline. Wine should not interfere with the treatment.

A client presents to the emergency department reporting vomiting, severe lower abdominal pain, and a tender mass above one testis. What action by the nurse is most important? a. Have the client rate pain using the 0-10 scale. b. Prepare to administer an IV opioid analgesic. c. Determine when he last ate or drank anything. d. Assess risk factors for testicular cancer.

ANS: C This client has signs and symptoms of testicular torsion, which is a surgical emergency. For client safety, the nurse assesses last oral intake. Rating the pain is an important intervention too but is not related to safety. The client cannot have opioids prior to signing a surgical consent. The client does not have signs and symptoms of testicular cancer.

A client has been treated for syphilis with IM penicillin. The next day the client calls the clinic to report fever, chills, achy muscles, and a worsening rash. What statement by the nurse is most appropriate? a. "You must be allergic to penicillin; over the counter antihistamines will help." b. "Please go to the nearest emergency department if you develop shortness of breath." c. "You can take acetaminophen or ibuprofen for the pain and achiness." d. "I think you should come in to the clinic either today or tomorrow and be checked."

ANS: C This client has signs of a Jarisch-Herxheimer reaction which is caused when the organisms' cell walls are disrupted and cellular contents are released rapidly. It is usually self-limiting and benign. Antipyretics and mild analgesics treat the symptoms. The client does not need to monitor for shortness of breath, come in to the clinic, or get antihistamines for an allergic reaction.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

ANS: C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.) a. Constipation for 3 days b. Temperature of 99 F c. Abdominal pain d. Visible blood in the urine e. Heavy vaginal bleeding

ANS: C, D, E Health teaching for a client having brachytherapy should emphasize reporting abdominal pain, visible blood in the urine, and heavy vaginal bleeding. Severe diarrhea (not constipation), urethral burning, extreme fatigue, and a fever over 100 F should also be reported.

The nurse is admitting a client who has acute glomerulonephritis caused by beta streptococcus. What drug therapy would the nurse expect to be prescribed for this client? a. Antihypertensives b. Antilipidemics c. Antidepressants d. Antibiotics

ANS: D Beta streptococcus is a bacterium that can cause acute glomerulonephritis, so antibiotic therapy is indicated.

The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when? c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?

ANS: D The client who has stress incontinence needs to strengthen the muscles of the pelvic floor using Kegel exercises. Catheterizations would not help with incontinence. Incontinence pads may need to be used by this client but that is not the most important thing to teach, and it does not help the client regain more control over his or her bladder.

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority? a. Might make the client feel jittery or nervous. b. Can cause sodium and fluid retention. c. Long-term effects include fat redistribution. d. Never stop prednisone abruptly.

ANS: D The nurse teaches the client to avoid stopping the drug abruptly as the priority because this can lead to a life-threatening adrenal crisis. Short-term side effects do include jitteriness or nervousness, sodium and water retention. One long-term side effect is fat redistribution resulting in "moon face" and "buffalo hump."

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information? a. "Methicillin-resistant Staphylococcus aureus can be hospital- or community-acquired." b. "Vancomycin-resistant Enterococcus can live on surfaces and be infectious for weeks." c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that break down antibiotics." d. "If you leave work wearing your scrubs, go directly home and wash them right away."

ANS: D To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving work. Keep work clothes separate from personal clothes. The nursing manager would need to correct his or her knowledge if he or she is letting staff know that wearing scrubs home is alright. The other statements are correct about multi-drug resistant organisms.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team

ANS: D A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99 F (37.2 C) d. Dusky color of the flap

ANS: D A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse should notify the surgeon to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but should be monitored.

A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf

ANS: D All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

ANS: D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.

A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)? a. Aid in the draining of the cysts by needle aspiration. b. Teach the client to wear a supportive bra to bed. c. Administer diuretics to decrease breast swelling. d. Obtain a cold pack to temporarily relieve the pain.

ANS: D All of the options would be comfort measures for a client with a fibrocystic breast condition. The UAP can obtain the cold or heat therapy. Only the nurse should aid the health care provider with a needle aspiration, teach, and administer medications.

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond? a. No genetic link is known, so your children are not at increased risk. b. Your sons will develop this disease because it has a sex-linked gene. c. Only if both you and your spouse are carriers of this disease. d. Each of your children has a 50% risk of having ADPKD.

ANS: D Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder

A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action? a. Feelings of anger that her partner infected her b. Loose stools over the last 2 days c. Anorexia and nausea d. Chills and a temperature of 101 F

ANS: D Chills and fever could indicate a persistent infection and the immediate need to alter the dose or type of antibiotic. Anger is a normal reaction to a sexually transmitted disease and the pain of pelvic inflammatory disease. Gastrointestinal symptoms are common side effects of antibiotics but not an immediate cause for intervention.

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. I should take my temperature daily and when I don't feel well. b. I will wash my toothbrush in the dishwasher once a week. c. I wont let anyone share any of my personal items or dishes. d. Its alright for me to keep my pets and change the litter box.

ANS: D Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching? a. Since you only have one kidney, a salt and fluid restriction is required. b. Your therapy will include hemodialysis while you recover. c. Medication will be prescribed to control your high blood pressure. d. You need to avoid participating in contact sports like football.

ANS: D Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy

The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is best? a. Let the client alone for a long period of reflection time. b. Ask friends and relatives to limit their visits. c. Tell the client that an emotional response is unacceptable. d. Create an atmosphere of acceptance and discussion.

ANS: D Discussion of a clients concerns about the presence of cancer and the potential for recurrence will provide emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives. An emotional response should be accepted.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the clients oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

ANS: D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

The outpatient clinic nurse has assessed a woman who reports a month-long history of feeling full, urinary frequency, and bloating. What action by the nurse is best? a. Obtain a clean catch urine specimen. b. Instruct the client on a 3-day diet history. c. Facilitate having a pelvic ultrasound. d. Teach the woman about CA-125 test.

ANS: D Evidence shows that women with ovarian cancer often have recognizable, early signs such as abdominal bloating, urinary frequency or urgency, feeling full or difficulty eating, and pelvic pain. The nurse should "think ovarian" and facilitate the client having a CA-125 blood test, which is a cancer antigen test. The other actions may or may not be needed, but with these symptoms, the client needs to be evaluated for ovarian cancer.

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the clients behavior, which statement by the nurse would be the most appropriate? a. The urine incontinence should not prevent you from socializing. b. You seem depressed and should seek more pleasant things to do. c. It is common for men at your age to have changes in mood. d. Nocturia could cause interruption of your sleep and cause changes in mood.

ANS: D Frequent visits to the bathroom during the night could cause sleep interruptions and affect the clients mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity.

A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this clients teaching? a. You must clean around your catheter daily with soap and water. b. Wash the vaginal weights with a 10% bleach solution after each use. c. Operations to repair your bladder are available, and you can consider these. d. Buy slacks with elastic waistbands that are easy to pull down.

ANS: D Functional urinary incontinence occurs as the result of problems not related to the clients bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

A 30-year-old male client is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? a. "Gardasil protects against all HPV strains." b. "You are too old to receive the vaccine." c. "Only females can receive the vaccine." d. "You will only need 1 dose of the vaccine."

ANS: D Gardasil is used to provide immunity for HPV types 6, 11, 16, and 18 and Gardasil 9 protects against 5 more strains. The vaccine is recommended for people aged 9 to 26 years of age, but Gardasil 9 can be given up to age 45. Both males and females can get the vaccine. Depending on the timing and type of vaccine, either 2 to 3 doses are required.

A 19-year-old female is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? a. Gardasil protects against all HPV strains. b. You are too young to receive the vaccine. c. Only females can receive the vaccine. d. This will lower your risk for cervical cancer.

ANS: D Gardasil is used to provide immunity for HPV types 6, 11, 16, and 18 that are high risk for cervical cancer and warts. The vaccine is recommended for people ages 10 to 26 years.

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this clients plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

ANS: D In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

A hospital unit is participating in a bioterrorism drill. A client is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the client? a. Airborne Precautions b. Contact Precautions c. Droplet Precautions d. Standard Precautions

ANS: D Only Standard Precautions are needed. No other special precautions are required for the client because inhalation anthrax is not spread person to person.

A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion

ANS: D Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.

A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

ANS: D Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.

After a vaginoplasty, what instruction by the nurse is most important? a. Avoid vaginal douching to prevent infection. b. Do not have sexual intercourse for at least 6 months. c. Use oil-based lubricants with the vaginal dilators. d. You must dilate the vagina several times a day for months.

ANS: D Self-care management for this client includes instructions to dilate the new vagina several times a day for months after the procedure, using water-based lubricant. The client also needs to douche regularly, especially after intercourse, to avoid infections. Sexual intercourse is another way to keep the vagina dilated.

While evaluating a male client for treatment of gonorrhea, which question is the most important for the nurse to ask? a. Do you have a history of sexually transmitted disease? b. When was your last sexual encounter? c. When did your symptoms begin? d. What are the names of your recent sexual partners?

ANS: D Sexual partners, as well as the client, should be tested and treated for gonorrhea. Asking about sexually transmitted disease history, last sexual encounter, and onset of symptoms would be helpful with the history taking, but the priority is treating the clients sexual partners to limit the spread of the disease.

While evaluating a client for treatment of gonorrhea, which question is the most important for the nurse to ask? a. "Do you have a history of sexually transmitted infection?" b. "When was your last sexual encounter?" c. "When did your symptoms begin?" d. "Can you remember your partners and contact them to get treated?"

ANS: D Sexual partners, as well as the client, should be tested and treated for gonorrhea. Asking about sexually transmitted infection history, last sexual encounter, and onset of symptoms would be helpful with the history taking, but the priority is treating the client's sexual partners to limit the spread of the infection.

A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol LA) d. Allopurinol (Zyloprim)

ANS: D Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Phenazopyridine is given to clients with urinary tract infections. Propantheline is an anticholinergic. Tolterodine is an anticholinergic with smooth muscle relaxant properties.

A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? a. Administering an antispasmodic for bladder spasms b. Managing pain through patient-controlled analgesia c. Applying ice to a swollen scrotum and penis d. Helping the client transfer from the bed to the chair

ANS: D The UAP could aid the client in transferring from the bed to the chair and with ambulation. The nurse would be responsible for medication administration, assessment of swelling, and the application of ice if needed.

A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess heart, lung, and bowel sounds. b. Check the hemoglobin and hematocrit levels. c. Evaluate the dressing for drainage. d. Empty the urine from the urinary catheter bag.

ANS: D The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.

The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be delegated to the unlicensed assistive personnel (UAP)? a. Reviewing the hematocrit and hemoglobin results b. Teaching the client to avoid lifting her 4-year-old grandson c. Assessing the level of pain and any drainage d. Drawing a shallow hot bath for comfort measures

ANS: D The UAP is able to provide comfort through a bath. The registered nurse should review any laboratory results, complete any teaching, and assess pain and discharge.

The nurse teaches a client with genital herpes about effective comfort measures. Which statement by the client indicates a need for further teaching by the nurse? a. I can apply warm towels or ice packs to the lesions. b. Sitz baths three times a day may help ease the pain. c. I understand there are anesthetic sprays and ointments. d. I really should try to limit urination due to the pain.

ANS: D The client should urinate frequently, not limit voiding. Voiding while in the shower or tub should lessen the discomfort. Warm compresses, ice packs, sitz baths, and anesthetic sprays and ointments are all effective comfort measures that can be used with genital herpes.

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Include support people, such as the male partner, in the decision making.

ANS: D The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often makes the decisions for care of the female. Women with a high risk for breast cancer can consider prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have more complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in the remaining mammary tissue.

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, I am anxious about having an ileal conduit. What is it like to have this drainage tube? How should the nurse respond? a. I will ask the provider to prescribe you an antianxiety medication. b. Would you like to discuss the procedure with your doctor once more? c. I think it would be nice to not have to worry about finding a bathroom. d. Would you like to speak with someone who has an ileal conduit?

ANS: D The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge. Medications for anxiety will not promote a positive self-image and a positive attitude, nor will discussing the procedure once more with the physician or hearing the nurses opinion.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50pack-year cigarette smoking history

ANS: D The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the clients record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the clients abdomen and vital signs

ANS: D The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the clients abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the clients urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the clients pulse.

ANS: D The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes

ANS: D The skin and mucous membranes are the most important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.

A nurse instructor is teaching a student nurse about the factors that have increased the number of people with sexually transmitted diseases (STDs) seen in practice. Which statement by the student indicates a lack of understanding? a. There are improved techniques to diagnose an STD used in practice. b. There is increased incidence of sexual abuse and sexual trafficking. c. Females feel safe using oral agents rather than a condom as contraception. d. The organisms causing STDs are all becoming more virulent.

ANS: D There is no evidence that the organisms that cause STDs are becoming more virulent, but a client may need to use another anti-infective if allergic or the protocol was not effective. Extensive histories are taken in the clinic of clients of all ages, as well as assessment of laboratory data such as cervical, urethral, oral, or rectal specimens and lesion samples for microbiology and virology. There are changes in sexual attitudes and practices, cultural factors, migration, and international travel. Women often think that the oral contraceptives protect them from an STD.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? a. Ensure the client is placed in protective isolation. b. Hand off a pregnant client to another nurse. c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta.

ANS: D This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facility's policy for handling and disposing of this type of waste. The other actions are not warranted.

Which action would the nurse teach to help the client prevent vulvovaginitis? a. Wipe back to front after urination. b. Cleanse the inner labial mucosa with soap and water. c. Use feminine hygiene sprays to avoid odor. d. Wear loose cotton underwear.

ANS: D To prevent vulvovaginitis, the client should wear cotton underwear. The client should wipe front to back after urination, not back to front. The client should cleanse the inner labial mucosa with water only, and avoid using feminine hygiene sprays.

A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help

ANS: D Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy. Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.

Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.

ANS: D, E Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

Conflicting answers from other edition ANS: A, B, C, E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple births c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse f. Infections with HPV

Conflicting answers from other edition ANS: A, B, F Smoking, multiple births, and infection with HPV are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer. Poor diet could lead to decreased immunity, which is a risk, but is not directly related. Giving birth before the age of 17 is a risk factor