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. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hours.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Positive pressure airflow in the client's room helps prevent airborne contaminants from entering, reducing the risk of infection.
2. This intervention creates a controlled environment suitable for clients with compromised immune systems.
3. The positive pressure airflow system pushes air out of the room, minimizing the risk of external pathogens entering.
4. This measure is crucial in protective isolation to protect the client from infections during the vulnerable post-transplant period.
Summary:
- Choice B is not directly related to infection prevention in protective isolation.
- Choice C is important for respiratory infections but is not a primary intervention for protective isolation.
- Choice D is relevant but does not directly address infection prevention measures in protective isolation.
A nurse is continuing to care for a client who is postoperative following surgical removal of an abdominal abscess. Which of the following actions should the nurse take?
- A. Obtain vital signs every 30 minutes.
- B. Elevate the client in a semi-Fowler's position.
- C. Apply oxygen.
- D. Monitor the client's level of consciousness.
Correct Answer: B
Rationale: The correct answer is B: Elevate the client in a semi-Fowler's position. Elevating the client in a semi-Fowler's position helps promote optimal lung expansion and ventilation, reducing the risk of postoperative complications such as atelectasis and pneumonia. This position also aids in preventing aspiration and promotes comfort.
Choice A: Obtaining vital signs every 30 minutes is important postoperatively, but it is not the most immediate action needed in this case.
Choice C: Applying oxygen may be necessary depending on the client's oxygen saturation levels, but it is not the most essential action to take at this point.
Choice D: Monitoring the client's level of consciousness is important, but it is not as critical as positioning the client correctly to prevent respiratory complications.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to excessive loss of proteins in the urine, specifically albumin. This results in proteinuria. Choice A, hyperalbuminemia, is incorrect as nephrotic syndrome actually causes hypoalbuminemia due to protein loss. Choice C, decreased serum lipid levels, is incorrect because nephrotic syndrome causes hyperlipidemia due to increased hepatic synthesis of lipoproteins. Choice D, decreased coagulation, is incorrect as nephrotic syndrome is associated with hypercoagulability due to loss of anticoagulant proteins in the urine.
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 best option because it addresses the client's concern about needing a blood transfusion during surgery by suggesting an effective proactive measure. Donating your own blood before surgery, known as autologous donation, ensures that you have your own blood available if needed, reducing the risk of transfusion reactions and complications. It allows for a personalized and safe option in case of blood loss during the procedure.
As for the other options:
A: This statement does not provide relevant information about blood transfusions.
B: This statement is inaccurate as total hip arthroplasty can result in significant blood loss requiring a transfusion.
D: While using screened donor blood reduces the risk of infusion reactions, it does not address the client's specific concern about needing a transfusion during surgery.
Therefore, option C is the most appropriate response as it directly addresses the client's query and offers a practical solution.