Nokea
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Painless vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Painless vaginal bleeding. Cervical cancer can present with abnormal vaginal bleeding, which may include bleeding between periods, after intercourse, or post-menopause. This is due to the abnormal growth of cells in the cervix. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typical manifestations of cervical cancer. Diarrhea and urinary hesitancy are more commonly associated with gastrointestinal or urinary tract issues, while unexplained weight gain can be linked to various factors such as hormonal imbalances or dietary changes.
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For each potential provider’s prescription, the nurse must select if the action is Anticipated, Nonessential, or Contraindicated for the client.
- A. Encourage the client to cough
- B. Elevate the head of the bed
- C. Assist the client to the bathroom
- D. Decrease oxygen to 1.5 L/min via nasal cannula
- E. Keep the client’s head in a midline position
- F. Initiate seizure precautions
Correct Answer: B, A, C, A
Rationale: The correct answer is based on the rationale below:
1. Elevate the head of the bed (B): This action is Anticipated as it helps prevent aspiration and promotes optimal respiratory function.
2. Encourage the client to cough (A): Also Anticipated as coughing helps clear secretions and maintain airway patency.
3. Assist the client to the bathroom (C): This is Non-essential unless there are specific concerns about the client's mobility or urgency.
4. Decrease oxygen to 1.5 L/min via nasal cannula (A): Contraindicated as it may compromise oxygenation, especially without proper assessment and orders.
Other choices:
- Keeping the client's head in a midline position (E) is not provided in the question stem, so it cannot be evaluated.
- Initiating seizure precautions (F) is not relevant to the client's immediate care based on the information given
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Bull's eye lesion
- C. Esophagitis
- D. Tophi
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus commonly affects the joints, leading to inflammation and pain. This is known as lupus arthritis. Other choices are incorrect: B (Bull's eye lesion) is associated with Lyme disease, C (Esophagitis) is inflammation of the esophagus which is not a common manifestation of lupus, and D (Tophi) are uric acid crystal deposits seen in gout, not lupus.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start IV with a large-bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start IV with a large-bore needle. This is the priority intervention because fluid resuscitation is crucial in managing burn injuries to prevent hypovolemic shock. Starting an IV line allows for prompt administration of fluids and medications. Administering analgesic medication (A) can wait until after fluid resuscitation. Increasing room temperature (B) is not a priority in burn management. Cleansing wounds (C) can be done after fluid resuscitation. Starting the IV line with a large-bore needle (D) takes precedence over other interventions to stabilize the client's condition.
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood instead of a friend.
- B. This surgery has minimal blood loss so you will not require a transfusion.
- C. You can donate your own blood a few weeks prior to this surgery.
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the correct answer because autologous blood donation involves donating your own blood before surgery to be transfused back to you if needed. This reduces the risk of transfusion reactions and ensures a compatible blood match. Option A is incorrect because family members are not typically required to donate blood for surgery. Option B is incorrect as total hip arthroplasty can involve significant blood loss. Option D is incorrect as even with screened donor blood, transfusion reactions can still occur.
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?
- B. After this procedure
- C. you will feel much better.
- D. Tell me why you are scared to have this procedure.
Correct Answer: D
Rationale: Rationale: The correct response is D because it demonstrates active listening and empathy by encouraging the client to express their fears. By asking the client to elaborate on their fears, the nurse can address specific concerns and provide appropriate support. This promotes trust and open communication between the nurse and client, leading to better outcomes.
Incorrect Responses:
A: This response assumes the fear is related to needles and does not address the client's specific concerns about the procedure.
B: This response is incomplete and does not acknowledge the client's fear.
C: This response minimizes the client's feelings and does not address the underlying fear.
Overall, these responses fail to address the client's emotional needs and may not effectively alleviate their fear or anxiety.