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Which common side effect of metolazone (Zaroxolyn) should the nurse instruct a patient to report to the health- care provider?
- A. Numb hands
- B. Gastrointestinal distress
- C. Muscle weakness
- D. Nightmares
Correct Answer: C
Rationale: The correct answer is C: Muscle weakness. Metolazone is a diuretic that can lead to low potassium levels, causing muscle weakness. Instructing the patient to report muscle weakness is crucial to prevent any potential serious complications. Numb hands, gastrointestinal distress, and nightmares are not commonly associated with metolazone and do not pose as immediate risks as muscle weakness does. It is essential to prioritize the most critical side effect to ensure the patient's safety and well-being.
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After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
- A. Page an anesthesiologist immediately and prepare to intubate the client
- B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary
- C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs
- D. Insert an indwelling urinary catheter and begin to infuse IV fluids as ordered
Correct Answer: B
Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.
The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
- A. Renal calculi
- B. Hematuria
- C. Delayed ejaculation
- D. Impotence
Correct Answer: B
Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment.
A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi.
C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy.
D: Impotence - Impotence is not a common side effect of BCG therapy.
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
- A. Comprehensive
- B. Focused
- C. Time-lapsed
- D. Emergency
Correct Answer: C
Rationale: The correct answer is C: Time-lapsed assessment. This type of assessment involves comparing baseline data with new data collected at a later time to evaluate changes in the client's condition. In this scenario, the nurse is reassessing the client a month later to determine if there have been any changes that require adjustments to the care plan.
A: Comprehensive assessment is an in-depth assessment done initially to gather detailed information about the client's overall health status.
B: Focused assessment is done to gather specific information related to a particular problem or issue.
D: Emergency assessment is performed in urgent situations to quickly identify and address life-threatening conditions.
A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
- A. Surgery
- B. Radiation
- C. Chemotherapy
- D. Immunotherapy
Correct Answer: A
Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.