Nokea
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
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The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?
- A. The 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numerical scale
- B. The 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes
- C. The 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night
- D. The 54-year-old client with cirrhosis and jaundice who is reporting having itching all over the body
Correct Answer: B
Rationale: A. The client with a pain rating of 6 out of 10 on a numerical scale needs attention, but the pain is not a life-threatening concern. B. Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The nurse should assess this client first. C. The client who is postcholecystectomy is reported as being stable and could be assessed last. D. The client reporting itching needs attention, but the itching is not a life-threatening concern.
The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching?
- A. If diarrhea persists for more than 96 hours, contact the health-care provider.
- B. Instruct the client to wash hands thoroughly before handling any type of food.
- C. Explain the importance of decreasing steroids gradually as instructed.
- D. Discuss how to collect all stool samples for the next 24 hours.
Correct Answer: B
Rationale: Handwashing prevents the spread of gastroenteritis, a key discharge teaching point. Persistent diarrhea is concerning but less specific, steroids are irrelevant, and stool collection is not routine.
The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan?
- A. Fluid volume deficit.
- B. Impaired tissue perfusion.
- C. Infection of surgical site.
- D. Risk for immunosuppression.
Correct Answer: A
Rationale: Fluid volume deficit is a key intraoperative concern due to blood loss and fluid shifts during abdominal perineal resection. Perfusion, infection, and immunosuppression are postoperative risks.
The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The client is one (1) day postoperative major abdominal surgery. Which client problem is priority?
- A. Impaired skin integrity.
- B. Fluid and electrolyte imbalance.
- C. Altered bowel elimination.
- D. Altered body image.
Correct Answer: B
Rationale: Fluid and electrolyte imbalance is the priority due to risks of dehydration or imbalances from surgery, impacting hemodynamic stability. Skin integrity, bowel elimination, and body image are secondary in the immediate postoperative period.