Nokea
A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?
- A. 25-year-old client who reports a fish-like vaginal odor for the past month
- B. 30-year-old client with an intrauterine device who reports heavy bleeding with menses
- C. 40-year-old client with endometriosis who reports persistent pain during intercourse
- D. 60-year-old client who reports bloating and pelvic pressure for the past 2 months
Correct Answer: D
Rationale: Bloating and pelvic pressure in a 60-year-old client may indicate serious conditions such as ovarian cancer or other pelvic masses, which require urgent evaluation. Fish-like odor suggests bacterial vaginosis, heavy bleeding with an IUD is common, and pain with endometriosis is expected, making these less concerning.
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A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.
- A. Avoid irritants such as acidic, spicy foods
- B. Discourage the use of topical analgesics
- C. Encourage liquid nutritional supplements
- D. Perform oral hygiene once per day
- E. Use artificial saliva to control dryness
Correct Answer: A,C,E
Rationale: Avoiding irritants reduces mucosal irritation. Liquid supplements ensure adequate nutrition when swallowing is difficult. E: Artificial saliva alleviates xerostomia, a common side effect. B is incorrect as topical analgesics may be beneficial for pain relief. D is incorrect as frequent oral hygiene is needed to prevent infections and maintain oral health.
The nurse is preparing to administer scheduled medications to assigned clients. Which of the following medications should the nurse hold for clarification prior to administering?
- A. magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.41 mmol/L)
- B. calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)
- C. clopidogrel for a client with a platelet count of 70,000/mm³ (70 × 10â¹/L)
- D. metformin for a client with a hemoglobin A1c level of 11%
Correct Answer: C
Rationale: Clopidogrel increases bleeding risk in a client with low platelets (70,000/mm³), requiring clarification. The other medications align with the clients' conditions.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
- A. High calorie, low fat, low sodium
- B. High protein, low fat, low carbohydrate
- C. High protein, high calorie, unrestricted fat
- D. High carbohydrate, low protein, moderate fat
Correct Answer: C
Rationale: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.
The nurse is teaching an elderly client how to use MDIs (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
- A. Nebulized treatments for home care
- B. Adding a spacer device to the MDI canister
- C. Asking a family member to assist the client with the MDI
- D. Request a visiting nurse to follow the client at home
Correct Answer: B
Rationale: If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.