Nokea
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?
Correct Answer: C
Rationale: 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.
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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.
Correct Answer: C
Rationale: 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 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 data]. Which action should the nurse take?
- 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.
Correct Answer: B
Rationale: 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 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)
Correct Answer: A
Rationale: 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 client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching?
- A. Family history of prostate cancer
- B. Smoking
- C. Obesity
- D. Advanced age
- E. Eating too much red meat
- F. Race
Correct Answer: A,D,E,F
Rationale: 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.
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 thing 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.
Correct Answer: D
Rationale: 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.