Nokea
The nurse is talking with a group of clients at a community health fair about colorectal cancer. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Clients over the age of 50 are at highest risk for colorectal cancer regardless of health status
- B. Consuming low amounts of red meat may reduce the risk for developing colorectal cancer
- C. Clients with inflammatory bowel disease are at higher risk for developing colorectal cancer
- D. Eating plenty of fruits and vegetables and maintaining a healthy weight may reduce the risk for developing colorectal cancer
- E. Clients with a parent or sibling who has had colorectal cancer should have screenings earlier and more often than other clients
Correct Answer: B,C,D,E
Rationale: Low red meat, high fruit/vegetable intake, and healthy weight reduce colorectal cancer risk. Inflammatory bowel disease and family history increase risk, necessitating earlier screenings. Risk rises after age 50, but health status matters, making the first statement inaccurate.
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The nurse is reviewing the plan of care for multiple clients receiving opioids for pain management. Which client has the greatest risk for respiratory depression?
- A. 20-year-old client with chronic bronchitis who is receiving inhaled albuterol therapy every 4 hours
- B. 30-year-old client with opioid use disorder who had rotator cuff repair surgery this morning
- C. 50-year-old client with sleep apnea and left foot cellulitis who is scheduled for a bone scan later today
- D. 70-year-old client with chronic obstructive pulmonary disease who had knee replacement this morning
Correct Answer: D
Rationale: The 70-year-old with COPD is at highest risk for opioid-induced respiratory depression due to age-related reduced lung capacity and COPD-related impaired gas exchange. Chronic bronchitis and opioid use disorder increase risk but are less severe in this context.
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don't we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let's check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.