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After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will take this medication with food and plenty of water.
- B. I shall keep my appointment at the infusion center each week.
- C. I'll limit my intake of green leafy vegetables while on this medication.
- D. I must not take this medication if I have an infection or am feeling ill.
Correct Answer: B
Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.
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After educating a client with stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I will limit my total intake of fluids.
- B. I must avoid drinking alcoholic beverages.
- C. I must avoid drinking caffeinated beverages.
- D. I shall try to lose about 10% of my body weight.
Correct Answer: A
Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.
A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?
- A. Checking the client's blood pressure
- B. Checking the oxygen saturation level
- C. Having the client take some deep breaths
- D. Lowering the head of the bed slowly until the dizziness is relieved
Correct Answer: D
Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.
A client is being prepared for a colonoscopy. Into which position does the nurse assist the client for the procedure?
- A. Left Sims' position
- B. Lithotomy position
- C. Knee-chest position
- D. Right Sims' position
Correct Answer: A
Rationale: During a colonoscopy, the client is positioned in the left Sims' position. This position is chosen as it optimally utilizes the client's anatomy to facilitate the introduction of the colonoscope. The lithotomy position (Choice B) is commonly used for gynecological exams, not colonoscopies. The knee-chest position (Choice C) is typically employed for rectal examinations or certain surgical procedures, not colonoscopies. The right Sims' position (Choice D) is a less common position for colonoscopy compared to the left Sims' position.
A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?
- A. Is there a family history of this problem?
- B. Do you consume cranberry juice?
- C. Do you urinate after sexual intercourse?
- D. Do you have burning sensation during urination?
Correct Answer: A
Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.
A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.