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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.
Correct Answer: B
Rationale: The source of infection should be removed first. All of the other answers are possible interventions depending on the client's symptoms and vital signs, but removing the tampon is the priority.
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A client who had a hysterectomy has a 200-mg dose of ciprofloxacin (Cipro) ordered to infuse in 30 minutes. At what rate should the nurse infuse the medication if the pharmacy provides 200 mg in a 100-mL bag of normal saline? (Record your answer using a whole number) mL/hr
- A. 200 mL/hr
- B. 100 mL/hr
- C. 150 mL/hr
- D. 250 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate: The pharmacy provides 200 mg in a 100-mL bag, to be infused over 30 minutes. Infusion rate (mL/hr) = Total volume (mL) ÷ Time (hr). Here, 100 mL ÷ 0.5 hr = 200 mL/hr.
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.
Correct Answer: B
Rationale: 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 younger women, 19-26 years, should receive an HPV vaccine. The 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 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 in detail the side effects of laparoscopic surgery.
- C. Reduce anxiety by relaxation techniques and education.
- D. Suggest resources such as the Endometriosis Association.
- E. Encourage the client to avoid all physical activity.
Correct Answer: A,C,D
Rationale: 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 like the Endometriosis Association. Discussing surgical side effects in detail is not appropriate without assessing the client's readiness, and avoiding all physical activity is not recommended as it may not help manage symptoms.
Which action would the nurse teach to help the client prevent vulvovaginitis?
- A. Wipe back 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.
Correct Answer: D
Rationale: 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 55-year-old post-menopausal woman is assessed by the nurse with a history of dyspareunia, backache, pelvic pressure, urinary tract infections, and frequent urinary urgency. Which condition does the nurse suggest?
- A. Ovarian cyst
- B. Rectocele
- C. Cystocele
- D. Fibroid
Correct Answer: C
Rationale: Dyspareunia, backache, pelvic pressure, urinary tract infections, and urinary urgency are all symptoms of a cystocele, a protrusion of the bladder through the vaginal wall. Ovarian cysts are rare after menopause, a rectocele is associated with constipation, hemorrhoids, and local impaction. Fibroids are associated with heavy bleeding.