Nokea
A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?
- A. Supported Sims
- B. Semi-Fowler’s
- C. Dorsal recumbent
- D. Prone
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler’s position. Placing the client in Semi-Fowler’s position after a cholecystectomy helps to promote optimal lung expansion and oxygenation. This position reduces pressure on the diaphragm and abdomen, allowing for improved respiratory function. Additionally, it helps prevent complications such as atelectasis and pneumonia. Supported Sims position (A) is used for enemas, not post-cholecystectomy care. Dorsal recumbent position (C) is for pelvic exams, not indicated here. Prone position (D) would put pressure on the abdomen and is contraindicated post-cholecystectomy.
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A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
- A. Tamoxifen
- B. Leuprolide
- C. Finasteride
- D. Cyclophosphamide
Correct Answer: B
Rationale: The correct answer is B: Leuprolide. Leuprolide is a gonadotropin-releasing hormone agonist that suppresses testosterone production, which can help slow the growth of prostate cancer. Tamoxifen (A) is used for breast cancer, Finasteride (C) is used for benign prostatic hyperplasia, and Cyclophosphamide (D) is a chemotherapy drug for various cancers. Therefore, in this case, the most appropriate medication for prostate cancer would be Leuprolide (B).
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
- A. Pruritus
- B. Swollen gums
- C. Dysphagia
- D. Urinary hesitancy
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia, difficulty swallowing, is a priority finding in an older adult male as it can lead to aspiration and malnutrition. The nurse needs to address this promptly to prevent complications. Pruritus (choice A) is itching and can be managed. Swollen gums (choice B) may indicate dental issues but are not immediately life-threatening. Urinary hesitancy (choice D) can be indicative of a urinary problem but does not pose an immediate risk compared to dysphagia.
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Distorted perceptual field.
- B. Urinary frequency.
- C. Rapid speech.
Correct Answer: C
Rationale: The correct answer is C: Rapid speech. In clients with moderate anxiety, rapid speech is a common finding due to the increased arousal and nervousness associated with anxiety. The individual may talk quickly as a way to cope with their anxiety. Distorted perceptual field (A) is more indicative of severe anxiety or psychosis. Urinary frequency (B) is not a typical finding in moderate anxiety, unless there are underlying medical issues. Rapid speech (C) aligns with the increased arousal and restlessness seen in moderate anxiety.
A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
- A. Intense pruritus
- B. Irregular borders
- C. Uniform pigmentation
- D. Purulent drainage
Correct Answer: B
Rationale: The correct answer is B: Irregular borders. Irregular borders are a classic sign of malignancy in nevi, suggesting potential melanoma. This finding indicates that the nevus may be evolving into a cancerous lesion. It is crucial for the nurse to report this to the provider promptly for further evaluation. Intense pruritus (choice A) is common in benign nevi and not specific to malignancy. Uniform pigmentation (choice C) is typically seen in benign nevi and is not a concerning feature. Purulent drainage (choice D) is more indicative of infection or inflammation rather than malignancy. In summary, irregular borders are a red flag for malignancy, while the other choices are more likely associated with benign nevi or other conditions.