Nokea
Which nursing order is most appropriate to add to the client's initial postoperative care plan?
- A. Connect the cystostomy tube to a leg bag for drainage.
- B. Secure the cystostomy tube to the client's thigh.
- C. Ensure that the cystostomy tube is unclamped at all times.
- D. Clamp the indwelling catheter when the cystostomy tube is irrigated.
Correct Answer: C
Rationale: Keeping the cystostomy tube unclamped ensures continuous drainage, preventing complications like infection or pressure buildup.
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The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make?
- A. The hospital social worker.
- B. CanSurmount.
- C. Reach to Recovery.
- D. I CanCope.
Correct Answer: C
Rationale: Reach to Recovery provides peer support from breast cancer survivors, addressing emotional and practical needs post-diagnosis. Social workers, CanSurmount, and I CanCope are valuable but less specific to breast cancer support.
The male client complains of mucus-like drainage from the rectum accompanied by rectal pain and diarrhea. Which interview question should the nurse ask the client?
- A. Do you have difficulty trying to urinate?'
- B. Have you had rectal sexual intercourse?'
- C. Do you eat a high-fiber diet and drink lots of fluids?'
- D. Does the diarrhea alternate with constipation?'
Correct Answer: B
Rationale: Rectal intercourse is a risk for proctitis or STDs causing mucus, pain, and diarrhea. Urination, diet, and diarrhea patterns are less specific.
Which statement is most accurate when discussing hair loss with the client?
- A. The hair loss is permanent, but attractive wigs are available.
- B. The hair loss is permanent, but hair transplantation is a possible solution.
- C. The hair loss is temporary; hair may grow back in several years.
- D. The hair loss is temporary; hair will regrow after chemotherapy is finished.
Correct Answer: D
Rationale: Hair loss from chemotherapy is typically temporary, with regrowth occurring after treatment ends, usually within months.
Before taking the client to the room where the pelvic examination will be performed, which nursing action is most appropriate?
- A. Ask the client to sign a consent form.
- B. Give the client a gown to wear.
- C. Offer the client a mild analgesic.
- D. Help the client instill a vaginal lubricant.
Correct Answer: B
Rationale: Providing a gown ensures the client's privacy and comfort during the pelvic examination, which is a priority before the procedure.
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.