Nokea
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
- A. Vertigo.
- B. Tinnitus.
- C. Nausea.
- D. Ataxia.
- E. Hearing loss.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.
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Which of the following is a risk factor for toxic shock syndrome (TSS)?
- A. Changing tampons every 3 hours.
- B. Avoiding use of deodorized tampons.
- C. Alternating tampons with sanitary pads.
- D. Using only tampons at night.
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
- A. Pale pink
- B. Bright red
- C. Dark pink
- D. Tea-colored
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.
The nurse is caring for a client taking memantine. Which data should the nurse monitor for this client?
- A. Liver function studies
- B. Complete blood count
- C. Renal function studies
- D. Pulmonary function studies
Correct Answer: C
Rationale: Memantine is a medication used to treat moderate to severe Alzheimer's disease. This medication needs to be avoided in clients with severe renal dysfunction, and a reduced dosage is needed in moderate renal dysfunction. The other options are not specifically associated with this medication.
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.