Nokea
A nurse teaches a client with vulvodynia about self-care. What statement indicates understanding?
- A. I should use scented soaps.
- B. I should avoid the use of any lubricants.
- C. I should wear tight synthetic underwear.
- D. I should use hot baths frequently.
Correct Answer: B
Rationale: The correct answer is B. Clients with vulvodynia should avoid the use of any lubricants to prevent irritation and exacerbation of symptoms. Lubricants can contain chemicals or fragrances that can further irritate the sensitive skin in the vulvar area. Choosing products specifically designed for sensitive skin or recommended by a healthcare provider is crucial. Using lubricants can worsen symptoms and discomfort.
Avoiding scented soaps (choice A) is important as well because fragrances can also irritate the vulvar area. Wearing tight synthetic underwear (choice C) can trap moisture and heat, leading to increased irritation. Using hot baths frequently (choice D) can also worsen symptoms by further irritating the sensitive skin.
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A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
- A. Provide frequent oral and nares care.
- B. Monitor the client's oxygen levels.
- C. Administer intravenous antibiotics.
- D. Remove the tube immediately after 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is caused by increased fibrinogen levels.
- C. DIC is caused by a reduction in platelet production.
- D. DIC is caused by a decrease in clotting factors.
Correct Answer: A
Rationale: The correct answer is A because DIC is characterized by abnormal coagulation involving fibrinogen. In septic shock, the body's response triggers widespread activation of the coagulation system, leading to the consumption of clotting factors like fibrinogen. This results in the formation of microclots throughout the body, leading to organ dysfunction. Choices B, C, and D are incorrect as DIC is not caused by increased fibrinogen levels, a reduction in platelet production, or a decrease in clotting factors. It is essential for the nurse to emphasize the role of abnormal coagulation involving fibrinogen in DIC to help the client understand the pathology and potential complications associated with septic shock.