Nokea
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.
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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.
The nurse is teaching the client diagnosed with uterine prolapse. Which information should the nurse include in the discussion?
- A. Increase fluids and daily exercise to prevent constipation.
- B. Explain there is only one acceptable treatment for uterine prolapse.
- C. Instruct the client to visually check the uterine prolapse daily.
- D. Discuss limiting coughing and lifting heavy objects.
Correct Answer: D
Rationale: Limiting coughing and heavy lifting reduces pelvic pressure, preventing prolapse worsening. Fluids and exercise aid bowel health but are secondary, multiple treatments exist, and daily visual checks are unnecessary.
The HCP has prescribed two (2) IV antibiotics for the female client diagnosed with diabetes and pneumonia. Which order should the nurse request from the HCP?
- A. Request written information on antibiotic-caused vaginal infections.
- B. Request yogurt to be served on the client’s meal trays.
- C. Request a change of one of the antibiotics to an oral route.
- D. Request L. acidophilus, a probiotic medication, three (3) times a day.
Correct Answer: D
Rationale: Probiotics like L. acidophilus prevent antibiotic-associated vaginal yeast infections. Written information is less proactive, yogurt is insufficient, and changing routes is unnecessary.
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.
In addition to pressure in the pelvic region, which sign or symptom is the client most likely to reveal during a nursing history?
- A. Heavy menstrual bleeding
- B. Light menstrual bleeding
- C. Abdominal pain at the time of ovulation
- D. Breast tenderness during menstruation
Correct Answer: A
Rationale: Fibroid tumors often cause heavy menstrual bleeding due to increased uterine surface area and vascularity.