Nokea
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.
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The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast tissue, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
Because many antineoplastic drugs affect bone marrow function, which laboratory test is most important to monitor for client safety?
- A. Mean cell volume
- B. Total leukocyte count
- C. Differential cell count
- D. Complete blood count
Correct Answer: D
Rationale: A complete blood count monitors red cells, white cells, and platelets, detecting bone marrow suppression caused by antineoplastic drugs.
Which nursing diagnosis is most appropriate for the nurse to add to the client's care plan at this time?
- A. Risk for ineffective airway clearance
- B. Risk for imbalanced nutrition
- C. Ineffective coping
- D. Impaired verbal communication
Correct Answer: A
Rationale: General anesthesia and abdominal surgery increase the risk of respiratory complications, making ineffective airway clearance a priority diagnosis.
The client has an infected Bartholin’s cyst and the HCP has performed an incision and drainage (I&D) of the area. Which discharge instructions should the nurse teach the client?
- A. Complete all antibiotics as ordered.
- B. Report any drainage immediately.
- C. Keep all water away from the area.
- D. Lie prone as much as possible.
Correct Answer: A
Rationale: Completing antibiotics prevents recurrence of infection post-I&D. Drainage is expected, water avoidance is impractical, and prone positioning is unnecessary.
The client diagnosed with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement? Select all that apply.
- A. Place the client in a private room.
- B. Wear a dosimeter when entering the room.
- C. Encourage visitors to come and stay with the client.
- D. Plan to spend extended time with the client.
- E. Notify the nuclear medicine technician.
Correct Answer: A,B
Rationale: Brachytherapy requires a private room and dosimeter use to minimize radiation exposure. Visitors are limited, extended nurse time is avoided, and nuclear medicine notification is unnecessary.