Nokea
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.
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The nurse is admitting a client diagnosed with trichomoniasis. Which assessment data support this diagnosis?
- A. Odorless, white, curdlike vaginal discharge.
- B. Strawberry spots on the vaginal surface and itching.
- C. Scant white vaginal discharge and dyspareunia.
- D. Purulent discharge from the endocervix and pelvic pain.
Correct Answer: B
Rationale: Trichomoniasis causes strawberry spots (petechiae) on the vagina and itching due to inflammation. Curdlike discharge is candidiasis, scant discharge/dyspareunia is nonspecific, and purulent discharge suggests PID.
If a culture is ordered to detect the causative organism, which body substance will the nurse collect?
- A. Venous blood
- B. Sterile urine
- C. Specialized semen
- D. Urethral drainage
Correct Answer: D
Rationale: Urethral drainage is the primary specimen for culturing gonorrhea, as it directly samples the infection site.
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 licensed practical nurse (LPN) realizes that the nursing assistant requires further instruction when observing which activities after the client's hysterectomy? Select all that apply.
- A. Frequently offering the client a variety of oral fluids
- B. Helping the client ambulate in the hall
- C. Raising the knee gatch on the hospital bed
- D. Reporting to the physician that the client's dressing is loose
- E. Changing the client's perineal pad without using gloves
Correct Answer: C,E
Rationale: Raising the knee gatch can impair circulation, and changing pads without gloves risks infection. Other actions are appropriate post-hysterectomy care.
Which vaccination should the nurse recommend to the postpubertal male to prevent orchitis?
- A. Yearly flu injections.
- B. Herpes varicella inoculations.
- C. Mumps vaccination.
- D. Rubella injections.
Correct Answer: C
Rationale: Mumps vaccination prevents mumps-related orchitis, a common cause in postpubertal males. Flu, varicella, and rubella are unrelated to orchitis.