Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP?
- A. Increase the drip rate on the Murphy drip irrigation set.
- B. Check the suprapubic catheter insertion site for infection.
- C. Encourage the two (2)-hour postoperative client to turn and cough.
- D. Document the amount of red drainage in the catheter.
Correct Answer: C
Rationale: Encouraging turning and coughing is within UAP scope to prevent respiratory complications. Adjusting irrigation, checking for infection, and documenting drainage require nursing judgment.
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Because the client is receiving this type of radiation therapy, which nursing interventions should the nurse include in the care plan? Select all that apply.
- A. Keep the client on strict bed rest.
- B. Limit the amount of time visitors stay with the client.
- C. Place urine and feces in a closed container.
- D. Weigh the client daily before breakfast.
- E. Stand at a distance and talk with the client from the doorway.
- F. Spend as little time as possible with the client.
Correct Answer: A,B,E,F
Rationale: Strict bed rest prevents dislodging the implant, limiting visitor time and nurse exposure reduces radiation risk, and standing at a distance minimizes exposure.
The nurse is caring for a client diagnosed with uterine cancer who has been receiving systemic therapy for six (6) months. Which intervention should the nurse implement first?
- A. Determine which antineoplastic medication the client has received.
- B. Ask the client if she has had any problems with mouth ulcers at home.
- C. Administer the biologic response modifier filgrastim (Neupogen).
- D. Encourage the client to discuss feelings about having cancer.
Correct Answer: B
Rationale: Mouth ulcers are a common chemotherapy side effect, requiring immediate assessment to manage pain and infection risk. Medication history, filgrastim administration, and emotional support are secondary.
The client diagnosed with cancer of the prostate has been placed on luteinizing hormone-releasing hormone (LHRH) agonist therapy. Which statement indicates the client understands the treatment?
- A. I will be able to function sexually as always.'
- B. I may have hot flashes while taking this drug.'
- C. This medication will cure the prostate cancer.'
- D. There are no side effects with this medication.'
Correct Answer: B
Rationale: LHRH agonists cause hot flashes due to hormonal suppression. Sexual dysfunction is common, cure is not guaranteed, and side effects are expected.
The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make?
- A. The hospital social worker.
- B. CanSurmount.
- C. Reach to Recovery.
- D. I CanCope.
Correct Answer: C
Rationale: Reach to Recovery provides peer support from breast cancer survivors, addressing emotional and practical needs post-diagnosis. Social workers, CanSurmount, and I CanCope are valuable but less specific to breast cancer support.
The male client complains of mucus-like drainage from the rectum accompanied by rectal pain and diarrhea. Which interview question should the nurse ask the client?
- A. Do you have difficulty trying to urinate?'
- B. Have you had rectal sexual intercourse?'
- C. Do you eat a high-fiber diet and drink lots of fluids?'
- D. Does the diarrhea alternate with constipation?'
Correct Answer: B
Rationale: Rectal intercourse is a risk for proctitis or STDs causing mucus, pain, and diarrhea. Urination, diet, and diarrhea patterns are less specific.