Nokea
A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix. Which of the following statements would be most accurate to include in the teaching plan about the potential effects of radiation therapy on sexuality?
- A. You can have sexual intercourse while the implant is in place.
- B. You may notice some vaginal dryness after treatment is completed.
- C. You may notice some vaginal relaxation after treatment is completed.
- D. You will continue to have normal menstrual periods during treatment.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect of cervical radiation due to mucosal changes, and should be included in the teaching plan to prepare the client.
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The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
- A. For administration of oxygen.
- B. To promote formation of lung scar tissue.
- C. To insert antibiotics into the pleural space.
- D. To remove air and fluid.
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.
During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
- A. A Bible.
- B. A picture.
- C. A sachet of lavender.
- D. A hairbrush.
Correct Answer: C
Rationale: During leukemia induction therapy, the client is immunocompromised, and scented items like a lavender sachet may harbor bacteria or cause allergic reactions. A Bible, picture, and hairbrush (if clean) are safe and support emotional well-being.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?
- A. The procedure will result in enlargement of the pyloric sphincter.
- B. The procedure will result in anastomosis of the gastric stump to the jejunum.
- C. The procedure will result in removal of the duodenum.
- D. The procedure will result in repositioning of the vagus nerve.
Correct Answer: B
Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?
- A. Administer the medications.
- B. Call the physician.
- C. Withhold the captopril.
- D. Question the metoprolol dose.
Correct Answer: B
Rationale: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.