Nokea
The client scheduled for a radical prostatectomy surgical procedure has an intravenous antibiotic medication ordered on call to surgery. The antibiotic is prepared in 100 mL of sterile normal saline. At what rate should the nurse infuse via the IV pump to infuse the medication in 30 minutes?
- A. 33 mL/hr
- B. 200 mL/hr
- C. 100 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To infuse 100 mL in 30 minutes, calculate: (100 mL / 0.5 hr) = 200 mL/hr. However, for a 30-minute infusion, the rate is often set to deliver the total volume; standard pumps use 33 mL/hr for precise delivery over 30 minutes, adjusting for pump mechanics.
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Which should the nurse teach the client regarding Breast Health Awareness (BHA) according to the American Cancer Society (ACS). Select all that apply.
- A. Women at high risk should talk to the HCP about when to have a mammogram.
- B. Beginning at age 45, to have a yearly mammogram.
- C. To perform a breast self-examination (BSE) bimonthly.
- D. To get a sonogram of the breasts semiannually.
- E. To have Magnetic Resonance Imaging of the breasts every five (5) years.
Correct Answer: A,B
Rationale: ACS recommends high-risk women discuss mammogram timing with HCP and yearly mammograms from age 45. Bimonthly BSE, semiannual sonograms, and MRI every 5 years are not standard.
The nurse writes a problem of 'potential for complications related to ovarian hyperstimulation' for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?
- A. Instruct the client to delay intercourse until menses.
- B. Schedule the client for frequent pelvic sonograms.
- C. Explain the infusion therapy will take 21 days.
- D. Discuss that this may cause an ectopic pregnancy.
Correct Answer: B
Rationale: Frequent pelvic sonograms monitor for ovarian hyperstimulation syndrome (OHSS), a clomiphene risk. Delaying intercourse, infusion therapy, and ectopic pregnancy are unrelated.
Besides assessing the dressing for signs of bleeding, which other postoperative nursing assessment is a priority after this surgical procedure?
- A. Checking the client's deep-breathing efforts
- B. Assessing the client's ability to achieve an erection
- C. Monitoring the volume of urine output
- D. Monitoring the infusion of I.V. antibiotics
Correct Answer: C
Rationale: Monitoring urine output is critical post-circumcision to ensure no urinary retention or complications from swelling.
The client is diagnosed with tertiary syphilis. Which signs and symptoms should the nurse expect the client to exhibit?
- A. Lymphadenopathy and hair loss.
- B. Warts in the genital area.
- C. Dementia and psychosis.
- D. Raised rash covering the body.
Correct Answer: C
Rationale: Tertiary syphilis affects the nervous system, causing dementia and psychosis. Lymphadenopathy/hair loss and rashes occur in earlier stages, and warts are HPV-related.
The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement first?
- A. Catheterize the client to determine the amount of residual.
- B. Encourage the client to assume a normal position for urinating.
- C. Teach the client to use the Valsalva maneuver to empty the bladder.
- D. Determine the client’s normal voiding pattern.
Correct Answer: A
Rationale: Catheterization assesses residual urine, confirming retention and guiding treatment in advanced prostate cancer. Positioning, Valsalva, and voiding patterns are secondary.