Nokea
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?
- A. Postcoital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.
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A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication
The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The first thing the RN should do before the delegation of care is
- A. Provide a time-frame for the completion of the client care
- B. Assure the PN that the RN will be available for assistance
- C. Ask about prior experience with similar clients
- D. Review the specific procedures unique to the assignment
Correct Answer: C
Rationale: The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN’s prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for the assigned clients.
The nurse is caring for a client with a history of sickle cell disease.
- A. Which intervention is most effective during a sickle cell crisis?
- B. Administer oxygen therapy.
- C. Encourage ambulation.
- D. Apply cold compresses to painful areas.
- E. Restrict fluid intake.
Correct Answer: A
Rationale: Oxygen therapy improves oxygenation, reducing sickling and tissue hypoxia during a sickle cell crisis. Ambulation is limited, cold compresses worsen vasoconstriction, and fluids are encouraged to prevent dehydration.