1220 GSG Unit 2 Past Paper PDF

1220 GSG UNIT 2 A STUDENT ASKS THE NURSE WHAT IS THE BEST WAY TO ASSESS A CLIENTS PAIN. WHICH RESPONSE BY THE NURSE IS BEST? ◼ a. Numeric pain scale ◼ b. Behavioral assessment ◼ c. Objective observation ◼ d. Clients self-report ◼ ANS: D Many ways to measure pain are in use, including numeric pain sc...

1220 GSG UNIT 2 A STUDENT ASKS THE NURSE WHAT IS THE BEST WAY TO ASSESS A CLIENTS PAIN. WHICH RESPONSE BY THE NURSE IS BEST? ◼ a. Numeric pain scale ◼ b. Behavioral assessment ◼ c. Objective observation ◼ d. Clients self-report ◼ ANS: D Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client. A NEW NURSE REPORTS TO THE PRECEPTING NURSE THAT A CLIENT REQUESTED PAIN MEDICATION, AND WHEN THE NURSE BROUGHT IT, THE CLIENT WAS SOUND ASLEEP. THE NURSE STATES THE CLIENT CANNOT POSSIBLY SLEEP WITH THE SEVERE PAIN THE CLIENT DESCRIBED. WHAT RESPONSE BY THE EXPERIENCED NURSE IS BEST? ◼ a. Being able to sleep doesnt mean pain doesnt exist. ◼ b. Have you ever experienced any type of pain? ◼ c. The client should be assessed for drug addiction. ◼ d. Youre right; I would put the medication back. ◼ ANS: A A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful purpose. THE NURSE IN THE SURGERY CLINIC IS DISCUSSING AN UPCOMING SURGICAL PROCEDURE WITH A CLIENT. WHAT INFORMATION PROVIDED BY THE NURSE IS MOST APPROPRIATE FOR THE CLIENTS LONG-TERM OUTCOME? ◼ a. At least you know that the pain after surgery will diminish quickly. ◼ b. Discuss acceptable pain control after your operation with the surgeon. ◼ c. Opioids often cause nausea but you wont have to take them for long. ◼ d. The nursing staff will give you pain medication when you ask them for it. ◼ ANS: B The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach. A NURSE IS ASSESSING PAIN ON A CONFUSED OLDER CLIENT WHO HAS DIFFICULTY WITH VERBAL EXPRESSION. WHAT PAIN ASSESSMENT TOOL WOULD THE NURSE CHOOSE FOR THIS ASSESSMENT? ◼ a. Numeric rating scale ◼ b. Verbal Descriptor Scale ◼ c. FACES Pain Scale-Revised ◼ d. Wong-Baker FACES Pain Scale ◼ ANS: C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. THE NURSE IS ASSESSING A CLIENTS PAIN AND HAS ELICITED INFORMATION ON THE LOCATION, QUALITY, INTENSITY, EFFECT ON FUNCTIONING, AGGRAVATING AND RELIEVING FACTORS, AND ONSET AND DURATION. WHAT QUESTION BY THE NURSE WOULD BE BEST TO ASK THE CLIENT FOR COMPLETING A COMPREHENSIVE PAIN ASSESSMENT? ◼ a. Are you worried about addiction to pain pills? ◼ b. Do you attach any spiritual meaning to pain? ◼ c. How high would you say your pain tolerance is? ◼ d. What pain rating would be acceptable to you? ◼ ANS: D A comprehensive pain assessment includes the items listed in the question plus the client’s opinion on a functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged. A NURSE IS ASSESSING PAIN IN AN OLDER ADULT. WHAT ACTION BY THE NURSE IS BEST? ◼ a. Ask only yes-or-no questions so the client doesnt get too tired. ◼ b. Give the client a picture of the pain scale and come back later. ◼ c. Question the client about new pain only, not normal pain from aging. ◼ d. Sit down, ask one question at a time, and allow the client to answer. ◼ ANS: D Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging. THE NURSE RECEIVES A HAND-OFF REPORT. ONE CLIENT IS DESCRIBED AS A DRUG SEEKER WHO IS OBSESSED WITH EVEN TINY CHANGES IN PHYSICAL CONDITION AND IS ON THE LIGHT CONSTANTLY ASKING FOR MORE PAIN MEDICATION. WHEN ASSESSING THIS CLIENTS PAIN, WHAT STATEMENT OR QUESTION BY THE NURSE IS MOST APPROPRIATE? ◼ a. Help me understand how pain is affecting you right now. ◼ b. I wish I could do more; is there anything I can get for you? ◼ c. You cannot have more pain medication for 3 hours. ◼ d. Why do you think the medication is not helping your pain? ◼ ANS: A This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is demanding may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the clients situation. Why questions are probing and often make clients defensive, plus the client may not have an answer for this question. A NURSE ON THE MEDICAL-SURGICAL UNIT HAS RECEIVED A HAND-OFF REPORT. WHICH CLIENT SHOULD THE NURSE SEE FIRST? ◼ a. Client being discharged later on a complicated analgesia regimen ◼ b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale ◼ c. Postoperative client who received oral opioid analgesia 45 minutes ago ◼ d. Client who has returned from physical therapy and is resting in the recliner ◼ ANS: B Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home. A STUDENT NURSE ASKS WHY SEVERAL CLIENTS ARE GETTING MORE THAN ONE TYPE OF PAIN MEDICATION INSTEAD OF VERY HIGH DOSES OF ONE MEDICATION. WHAT RESPONSE BY THE REGISTERED NURSE IS BEST? ◼ a. A multimodal approach is the preferred method of control. ◼ b. Doctors are much more liberal with pain medications now. ◼ c. Pain is so complex it takes different approaches to control it. ◼ d. Clients are consumers and they demand lots of pain medicine. ◼ ANS: C Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences. A CLIENT WHO HAD SURGERY HAS EXTREME POSTOPERATIVE PAIN THAT IS WORSENED WHEN TRYING TO PARTICIPATE IN PHYSICAL THERAPY. WHAT INTERVENTION FOR PAIN MANAGEMENT DOES THE NURSE INCLUDE IN THE CLIENTS CARE PLAN? ◼ a. As-needed pain medication after therapy ◼ b. Client-controlled analgesia with a basal rate ◼ c. Pain medications prior to therapy only ◼ d. Round-the-clock analgesia with PRN analgesics ◼ ANS: D ◼ Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy. A NURSE ON THE POSTOPERATIVE INPATIENT UNIT RECEIVES A HAND-OFF REPORT ON FOUR CLIENTS USING PATIENT- CONTROLLED ANALGESIA (PCA) PUMPS. WHICH CLIENT SHOULD THE NURSE SEE FIRST? ◼ a. Client who appears to be sleeping soundly ◼ b. Client with no bolus request in 6 hours ◼ c. Client who is pressing the button every 10 minutes ◼ d. Client with a respiratory rate of 8 breaths/min ◼ ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain. A REGISTERED NURSE (RN) AND NURSING STUDENT ARE CARING FOR A CLIENT WHO IS RECEIVING PAIN MEDICATION VIA PATIENT-CONTROLLED ANALGESIA (PCA). WHAT ACTION BY THE STUDENT REQUIRES THE RN TO INTERVENE? ◼ a. Assesses the clients pain level per agency policy ◼ b. Monitors the clients respiratory rate and sedation ◼ c. Presses the button when the client cannot reach it ◼ d. Reinforces client teaching about using the PCA pump ◼ ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate. A CLIENT IS PUT ON TWICE-DAILY ACETAMINOPHEN (TYLENOL) FOR OSTEOARTHRITIS. WHAT FINDING IN THE CLIENTS HEALTH HISTORY WOULD LEAD THE NURSE TO CONSULT WITH THE PROVIDER OVER THE CHOICE OF MEDICATION? ◼ a. 25pack-year smoking history ◼ b. Drinking 3 to 5 beers a day ◼ c. Previous peptic ulcer ◼ d. Taking warfarin (Coumadin) ◼ ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem. A HOSPITALIZED CLIENT USES A TRANSDERMAL FENTANYL (DURAGESIC) PATCH FOR CHRONIC PAIN. WHAT ACTION BY THE NURSE IS MOST IMPORTANT FOR CLIENT SAFETY? ◼ a. Assess and record the clients pain every 4 hours. ◼ \b. Ensure the client is eating a high-fiber diet. ◼ c. Monitor the clients bowel function every shift. ◼ d. Remove the old patch when applying the new one. ◼ ANS: D The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety. AN EMERGENCY DEPARTMENT (ED) MANAGER WISHES TO START OFFERING CLIENTS NONPHARMACOLOGIC PAIN CONTROL METHODOLOGIES AS AN ADJUNCT TO MEDICATION. WHICH STRATEGY WOULD BE MOST SUCCESSFUL WITH THIS CLIENT POPULATION? ◼ a. Listening to music on a headset ◼ b. Participating in biofeedback ◼ c. Playing video games ◼ d. Using guided imagery ◼ ANS: A Listening to music on a headset would be the most successful cognitive-behavioral pain control method for several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be beneficial without strong concentration. A wide selection of music will make this appealing to more people. AN OLDER CLIENT WHO LIVES ALONE IS BEING DISCHARGED ON OPIOID ANALGESICS. WHAT ACTION BY THE NURSE IS MOST IMPORTANT? ◼ a. Discuss the need for home health care. ◼ b. Give the client follow-up information. ◼ c. Provide written discharge instructions. ◼ d. Request a home safety assessment. ◼ ANS: D All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client. A CLIENT IS BEING DISCHARGED FROM THE HOSPITAL AFTER SURGERY ON HYDROCODONE AND ACETAMINOPHEN (LORCET). WHAT DISCHARGE INSTRUCTION IS MOST IMPORTANT FOR THIS CLIENT? ◼ a. Call the doctor if the Lorcet does not relieve your pain. ◼ b. Check any over-the-counter medications for acetaminophen. ◼ c. Eat more fiber and drink more water to prevent constipation. ◼ d. Keep your follow-up appointment with the surgeon as scheduled. ◼ ANS: B All instructions are appropriate for this client. However, advising the client to check over-the-counter medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day. A FACULTY MEMBER EXPLAINS TO STUDENTS THE PROCESS BY WHICH PAIN IS PERCEIVED BY THE CLIENT. WHICH PROCESSES DOES THE FACULTY MEMBER INCLUDE IN THE DISCUSSION? (SELECT ALL THAT APPLY.) ◼ a. Induction ◼ b. Modulation ◼ c. Sensory perception ◼ d. Transduction ◼ e. Transmission ◼ ANS: B, C, D, E The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission. A FACULTY MEMBER EXPLAINS THE CONCEPTS OF ADDICTION, TOLERANCE, AND DEPENDENCE TO STUDENTS. WHICH INFORMATION IS ACCURATE? (SELECT ALL THAT APPLY.) ◼ a. Addiction is a chronic physiologic disease process. ◼ b. Physical dependence and addiction are the same thing. ◼ c. Pseudoaddiction can result in withdrawal symptoms. ◼ d. Tolerance is a normal response to regular opioid use. ◼ e. Tolerance is said to occur when opioid effects decrease. ◼ ANS: A, D, E Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease. A CLIENT WITH A BROKEN ARM HAS HAD ICE PLACED ON IT FOR 20 MINUTES. A SHORT TIME AFTER THE ICE WAS REMOVED, THE CLIENT REPORTS THAT THE EFFECT HAS WORN OFF AND REQUESTS PAIN MEDICATION, WHICH CANNOT BE GIVEN YET. WHAT ACTIONS BY THE NURSE ARE MOST APPROPRIATE? (SELECT ALL THAT APPLY.) ◼ a. Ask for a physical therapy consult. ◼ b. Educate the client on cold therapy. ◼ c. Offer to provide a heating pad. ◼ d. Repeat the ice application. ◼ e. Teach the client relaxation techniques. ◼ ANS: B, D, E Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury. A STUDENT NURSE LEARNS THAT THERE ARE PHYSICAL CONSEQUENCES TO UNRELIEVED PAIN. WHICH FACTORS ARE INCLUDED IN THIS PROBLEM? (SELECT ALL THAT APPLY.) ◼ a. Decreased immune response ◼ b. Development of chronic pain ◼ c. Increased gastrointestinal (GI) motility ◼ d. Possible immobility ◼ e. Slower healing ◼ ANS: A, B, D, E There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand. A NURSING STUDENT IS STUDYING PAIN SOURCES. WHICH STATEMENTS ACCURATELY DESCRIBE DIFFERENT TYPES OF PAIN? (SELECT ALL THAT APPLY.) ◼ a. Neuropathic pain sometimes accompanies amputation. ◼ b. Nociceptive pain originates from abnormal pain processing. ◼ c. Deep somatic pain is pain arising from bone and connective tissues. ◼ d. Somatic pain originates from skin and subcutaneous tissues. ◼ e. Visceral pain is often diffuse and poorly localized. ◼ ANS: A, C, D, E Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain. A NURSE ON THE POSTOPERATIVE UNIT ADMINISTERS MANY OPIOID ANALGESICS. WHAT ACTIONS BY THE NURSE ARE BEST TO PREVENT UNWANTED SEDATION AS A COMPLICATION OF THESE MEDICATIONS? (SELECT ALL THAT APPLY.) ◼ a. Avoid using other medications that cause sedation. ◼ b. Delay giving medication if the client is sleeping. ◼ c. Give the lowest dose that produces good control. ◼ d. Identify clients at high risk for unwanted sedation. ◼ e. Use an oximeter to monitor clients receiving analgesia. ◼ ANS: A, C, D, E Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the clients oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later. A NURSE IN THE ONCOLOGY CLINIC IS PROVIDING PREOPERATIVE EDUCATION TO A CLIENT JUST DIAGNOSED WITH CANCER. THE CLIENT HAS BEEN SCHEDULED FOR SURGERY IN 3 DAYS. WHAT ACTION BY THE NURSE IS BEST? ◼ a. Call the client at home the next day to review teaching. ◼ b. Give the client information about a cancer support group. ◼ c. Provide all the preoperative instructions in writing. ◼ d. Reassure the client that surgery will be over soon. ◼ ANS: A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the clients ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching. A CLIENT IN THE ONCOLOGY CLINIC REPORTS HER FAMILY IS FRUSTRATED AT HER ONGOING FATIGUE 4 MONTHS AFTER RADIATION THERAPY FOR BREAST CANCER. WHAT RESPONSE BY THE NURSE IS MOST APPROPRIATE? ◼ a. Are you getting adequate rest and sleep each day? ◼ b. It is normal to be fatigued even for years afterward. ◼ c. This is not normal and Ill let the provider know. ◼ d. Try adding more vitamins B and C to your diet. ◼ ANS: B Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is normal. A CLIENT TELLS THE ONCOLOGY NURSE ABOUT AN UPCOMING VACATION TO THE BEACH TO CELEBRATE COMPLETING RADIATION TREATMENTS FOR CANCER. WHAT RESPONSE BY THE NURSE IS MOST APPROPRIATE? ◼ a. Avoid getting salt water on the radiation site. ◼ b. Do not expose the radiation area to direct sunlight. ◼ c. Have a wonderful time and enjoy your vacation! ◼ d. Remember you should not drink alcohol for a year. ◼ ANS: B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate. A CLIENT IS RECEIVING CHEMOTHERAPY THROUGH A PERIPHERAL IV LINE. WHAT ACTION BY THE NURSE IS MOST IMPORTANT? ◼ a. Assessing the IV site every hour ◼ b. Educating the client on side effects\ ◼ c. Monitoring the client for nausea ◼ d. Providing warm packs for comfort ◼ ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further. A CLIENT WITH CANCER IS ADMITTED TO A SHORT-TERM REHABILITATION FACILITY. THE NURSE PREPARES TO ADMINISTER THE CLIENTS ORAL CHEMOTHERAPY MEDICATIONS. WHAT ACTION BY THE NURSE IS MOST APPROPRIATE? ◼ a. Crush the medications if the client cannot swallow them. ◼ b. Give one medication at a time with a full glass of water. ◼ c. No special precautions are needed for these medications. ◼ d. Wear personal protective equipment when handling the medications. ◼ ANS: D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed. THE NURSE WORKING WITH ONCOLOGY CLIENTS UNDERSTANDS THAT WHICH AGE-RELATED CHANGE INCREASES THE OLDER CLIENTS SUSCEPTIBILITY TO INFECTION DURING CHEMOTHERAPY? ◼ a. Decreased immune function ◼ b. Diminished nutritional stores ◼ c. Existing cognitive deficits ◼ d. Poor physical reserves ◼ ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves. AFTER RECEIVING THE HAND-OFF REPORT, WHICH CLIENT SHOULD THE ONCOLOGY NURSE SEE FIRST? ◼ a. Client who is afebrile with a heart rate of 108 beats/min ◼ b. Older client on chemotherapy with mental status changes ◼ c. Client who is neutropenic and in protective isolation ◼ d. Client scheduled for radiation therapy today ◼ ANS: B Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward. A CLIENT HAS A PLATELET COUNT OF 9800/MM3. WHAT ACTION BY THE NURSE IS MOST APPROPRIATE? ◼ a. Assess the client for calf pain, warmth, and redness. ◼ b. Instruct the client to call for help to get out of bed. ◼ c. Obtain cultures as per the facility’s standing policy. ◼ d. Place the client on protective isolation precautions. ◼ ANS: B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts. A CLIENT HOSPITALIZED FOR CHEMOTHERAPY HAS A HEMOGLOBIN OF 6.1 MG/DL. WHAT MEDICATION SHOULD THE NURSE PREPARE TO ADMINISTER? ◼ a. Epoetin alfa (Epogen) ◼ b. Filgrastim (Neupogen) ◼ c. Mesna (Mesnex) ◼ d. Oprelvekin (Neumega) ◼ ANS: A The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count. A NURSE WORKS WITH CLIENTS WHO HAVE ALOPECIA FROM CHEMOTHERAPY. WHAT ACTION BY THE NURSE TAKES PRIORITY? ◼ a. Helping clients adjust to their appearance ◼ b. Reassuring clients that this change is temporary ◼ c. Referring clients to a reputable wig shop ◼ d. Teaching measures to prevent scalp injury ◼ ANS: D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury. A CLIENT WITH A HISTORY OF PROSTATE CANCER IS IN THE CLINIC AND REPORTS NEW ONSET OF SEVERE LOW BACK PAIN. WHAT ACTION BY THE NURSE IS MOST IMPORTANT? ◼ a. Assess the client’s gait and balance. ◼ b. Ask the client about the ease of urine flow. ◼ c. Document the report completely. ◼ d. Inquire about the client’s job risks. ◼ ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating. THE NURSE HAS TAUGHT A CLIENT WITH CANCER WAYS TO PREVENT INFECTION. WHAT STATEMENT BY THE CLIENT INDICATES THAT MORE TEACHING IS NEEDED? ◼ a. I should take my temperature daily and when I dont feel well. ◼ b. I will wash my toothbrush in the dishwasher once a week. ◼ c. I wont let anyone share any of my personal items or dishes. ◼ d. Its alright for me to keep my pets and change the litter box. ◼ ANS: D Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management. A CLIENT HAS RECEIVED A DOSE OF ONDANSETRON (ZOFRAN) FOR NAUSEA. WHAT ACTION BY THE NURSE IS MOST IMPORTANT? ◼ a. Assess the client for a headache. ◼ b. Assist the client in getting out of bed. ◼ c. Instruct the client to reduce salt intake. ◼ d. Weigh the client daily before the client eats. ◼ ANS: B Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the clients risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug. A CLIENT IS ADMITTED WITH SUPERIOR VENA CAVA SYNDROME. WHAT ACTION BY THE NURSE IS MOST APPROPRIATE? ◼ a. Administer a dose of allopurinol (Aloprim). ◼ b. Assess the clients serum potassium level. ◼ c. Gently inquire about advance directives. ◼ d. Prepare the client for emergency surgery. ◼ ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome. THE STUDENT NURSE CARING FOR CLIENTS WHO HAVE CANCER UNDERSTANDS THAT THE GENERAL CONSEQUENCES OF CANCER INCLUDE WHICH CLIENT PROBLEMS? (SELECT ALL THAT APPLY.) ◼ a. Clotting abnormalities from thrombocythemia ◼ b. Increased risk of infection from white blood cell deficits ◼ c. Nutritional deficits such as early satiety and cachexia ◼ d. Potential for reduced gas exchange ◼ e. Various motor and sensory deficits ◼ ANS: B, C, D, E The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets). A NURSE IS PREPARING TO ADMINISTER IV CHEMOTHERAPY. WHAT SUPPLIES DOES THIS NURSE NEED? (SELECT ALL THAT APPLY.) ◼ a. Chemo gloves ◼ b. Facemask ◼ c. Isolation gown ◼ d. N95 respirator ◼ e. Shoe covers ◼ ANS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required. A CLIENT HAS THROMBOCYTOPENIA. WHAT ACTIONS DOES THE NURSE DELEGATE TO THE UNLICENSED ASSISTIVE PERSONNEL (UAP)? (SELECT ALL THAT APPLY.) ◼ a. Apply the clients shoes before getting the client out of bed. ◼ b. Assist the client with ambulation. ◼ c. Shave the client with a safety razor only. ◼ d. Use a lift sheet to move the client up in bed. ◼ e. Use the Waterpik on a low setting for oral care. ◼ ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care. A CLIENT HAS MUCOSITIS. WHAT ACTIONS BY THE NURSE WILL IMPROVE THE CLIENTS NUTRITION? (SELECT ALL THAT APPLY.) ◼ a. Assist with rinsing the mouth with saline frequently. ◼ b. Encourage the client to eat room-temperature foods. ◼ c. Give the client hot liquids to hold in the mouth. ◼ d. Provide local anesthetic medications to swish and spit. ◼ e. Remind the client to brush teeth gently after each meal. ◼ ANS: A, B, D, E Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids would be painful for the client. A NURSE CARES FOR A CLIENT WHO HAS DEVELOPED ESOPHAGITIS AFTER UNDERGOING RADIATION THERAPY FOR LUNG CANCER. WHICH DIET SELECTION SHOULD THE NURSE PROVIDE FOR THIS CLIENT? ◼ a. Spaghetti with meat sauce, ice cream ◼ b. Chicken soup, grilled cheese sandwich ◼ c. Omelet, soft whole wheat bread ◼ d. Pasta salad, custard, orange juice ◼ ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic. THE NURSE IS CARING FOR A CLIENT WITH LUNG CANCER WHO STATES, I DONT WANT ANY PAIN MEDICATION BECAUSE I AM AFRAID ILL BECOME ADDICTED. HOW SHOULD THE NURSE RESPOND? ◼ a. I will ask the provider to change your medication to a drug that is less potent. ◼ b. Would you like me to use music therapy to distract you from your pain? ◼ c. It is unlikely you will become addicted when taking medicine for pain. ◼ d. Would you like me to give you acetaminophen (Tylenol) instead? ◼ ANS: C Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication. WITH A HISTORY OF BREAST CANCER IN THE FAMILY, A 48-YEAR-OLD FEMALE CLIENT IS INTERESTED IN LEARNING ABOUT THE MODIFIABLE RISK FACTORS FOR BREAST CANCER. AFTER THE NURSE EXPLAINS THIS INFORMATION, WHICH STATEMENT MADE BY THE CLIENT INDICATES THAT MORE TEACHING IS NEEDED? ◼ a. I am fortunate that I breast-fed each of my three children for 12 months. ◼ b. It looks as though I need to start working out at the gym more often. ◼ c. I am glad that we can still have wine with every evening meal. ◼ d. When I have menopausal symptoms, I must avoid hormone replacement therapy. ◼ ANS: C Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for breast cancer prevention. A CLIENT HAS JUST RETURNED FROM A RIGHT RADICAL MASTECTOMY. WHICH ACTION BY THE UNLICENSED ASSISTIVE PERSONNEL (UAP) WOULD THE NURSE CONSIDER UNSAFE? ◼ a. Checking the amount of urine in the urine catheter collection bag ◼ b. Elevating the right arm on a pillow ◼ c. Taking the blood pressure on the right arm ◼ d. Encouraging the client to squeeze a rolled washcloth ◼ ANS: C Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions. A CLIENT IS DISCHARGED TO HOME AFTER A MODIFIED RADICAL MASTECTOMY WITH TWO DRAINAGE TUBES. WHICH STATEMENT BY THE CLIENT WOULD INDICATE THAT FURTHER TEACHING IS NEEDED? ◼ a. I am glad that these tubes will fall out at home when I finally shower. ◼ b. I should measure the drainage each day to make sure it is less than an ounce. ◼ c. I should be careful how I lie in bed so that I will not kink the tubing. ◼ d. If there is a foul odor from the drainage, I should contact my doctor. ◼ ANS: A The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a days time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the doctor should be contacted immediately. DURING DRESSING CHANGES, THE NURSE ASSESSES A CLIENT WHO HAS HAD BREAST RECONSTRUCTION. WHICH FINDING WOULD CAUSE THE NURSE TO TAKE IMMEDIATE ACTION? ◼ a. Slightly reddened incisional area ◼ b. Blood pressure of 128/75 mm Hg ◼ c. Temperature of 99 F (37.2 C) ◼ d. Dusky color of the flap ◼ ANS: D A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse should notify the surgeon to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but should be monitored. A CLIENT IS CONCERNED ABOUT THE RISK OF LYMPHEDEMA AFTER A MASTECTOMY. WHICH RESPONSE BY THE NURSE IS BEST? ◼ a. You do not need to worry about lymphedema since you did not have radiation therapy. ◼ b. A risk factor for lymphedema is infection, so wear gloves when gardening outside. ◼ c. Numbness, tingling, and swelling are common sensations after a mastectomy. ◼ d. The risk for lymphedema is a real threat and can be very self-limiting. ◼ ANS: B Infection can create lymphedema; therefore, the client needs to be cautious with activities using the affected arm, such as gardening. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and the presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives. THE NURSE IS TAKING A HISTORY OF A 68-YEAR-OLD WOMAN. WHAT ASSESSMENT FINDINGS WOULD INDICATE A HIGH RISK FOR THE DEVELOPMENT OF BREAST CANCER? (SELECT ALL THAT APPLY.) ◼ a. Age greater than 65 years ◼ b. Increased breast density ◼ c. Osteoporosis ◼ d. Multiparity ◼ e. Genetic factors ◼ ANS: A, B, E The high risk factors for breast cancer are age greater than 65 with the risk increasing until age 80; an increase in breast density because of more glandular and connective tissue; and inherited mutations of BRCA1 and/or BRCA2 genes. Osteoporosis and multiparity are not risk factors for breast cancer. A high postmenopausal bone density and nulliparity are moderate and low increased risk factors, respectively. THE NURSE IS FORMULATING A TEACHING PLAN ACCORDING TO EVIDENCE-BASED BREAST CANCER SCREENING GUIDELINES FOR A 50-YEAR-OLD WOMAN WITH LOW RISK FACTORS. WHICH DIAGNOSTIC METHODS SHOULD BE INCLUDED IN THE PLAN? (SELECT ALL THAT APPLY.) ◼ a. Annual mammogram ◼ b. Magnetic resonance imaging (MRI) ◼ c. Breast ultrasound ◼ d. Breast self-awareness ◼ e. Clinical breast examination ◼ ANS: A, D, E Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast self- awareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue. AFTER A BREAST EXAMINATION, THE NURSE IS DOCUMENTING ASSESSMENT FINDINGS THAT INDICATE POSSIBLE BREAST CANCER. WHICH ABNORMAL FINDINGS NEED TO BE INCLUDED AS PART OF THE CLIENT’S ELECTRONIC MEDICAL RECORD? (SELECT ALL THAT APPLY.) ◼ a. Peau D’orange ◼ b. Dense breast tissue ◼ c. Nipple retraction ◼ d. Mobile mass at two o’clock ◼ e. Nontender axillary nodes ◼ ANS: A, C, D In the documentation of a breast mass, skin changes such as dimpling (peau d’orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the face of a clock. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer. A NURSE IS CARING FOR FOUR POSTOPERATIVE CLIENTS WHO EACH HAD A TOTAL ABDOMINAL HYSTERECTOMY. WHICH CLIENT SHOULD THE NURSE ASSESS FIRST UPON INITIAL ROUNDING? ◼ a. Client who has had two saturated perineal pads in the last 2 hours ◼ b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg ◼ c. Client who has pain of 4 on a scale of 0 to 10 ◼ d. Client with a urinary catheter output of 150 mL in the last 3 hours ◼ ANS: A Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first. THE NURSE IS DOING PREOPERATIVE TEACHING FOR A CLIENT WHO IS SCHEDULED FOR REMOVAL OF CERVICAL POLYPS IN THE OFFICE. WHICH STATEMENT BY THE CLIENT INDICATES A CORRECT UNDERSTANDING OF THE PROCEDURE? ◼ a. I hope that I do not have cancer of the cervix. ◼ b. There should be little or no discomfort during the procedure. ◼ c. There may be a lot of bleeding after the polyp is removed. ◼ d. This may prevent me from having any more children. ◼ ANS: B Polyp removal is a simple office procedure with the client feeling no pain. The other responses are incorrect. Cervical polyps are the most common benign growth of the cervix. Cautery is used to stop any bleeding, and there is no evidence that cervical polyps have a relationship to childbearing. A CLIENT HAS SCHEDULED BRACHYTHERAPY SESSIONS AND STATES THAT SHE FEELS AS THOUGH SHE IS NOT SAFE AROUND HER FAMILY. WHAT IS THE BEST RESPONSE BY THE NURSE? ◼ a. You are only reactive when the radioactive implant is in place. ◼ b. To be totally safe, it is a good idea to sleep in a separate room. ◼ c. It is best to stay a safe distance from friends or family between treatments. ◼ d. You should use a separate bathroom from the rest of the family. ◼ ANS: A In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments. A CLIENT HAS JUST RETURNED FROM A TOTAL ABDOMINAL HYSTERECTOMY AND NEEDS POSTOPERATIVE NURSING CARE. WHAT ACTION CAN THE NURSE DELEGATE TO THE UNLICENSED ASSISTIVE PERSONNEL (UAP)? ◼ a. Assess heart, lung, and bowel sounds. ◼ b. Check the hemoglobin and hematocrit levels. ◼ c. Evaluate the dressing for drainage. ◼ d. Empty the urine from the urinary catheter bag. ◼ ANS: D The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing. THE NURSE IS GIVING DISCHARGE INSTRUCTIONS TO A CLIENT WHO HAD A TOTAL ABDOMINAL HYSTERECTOMY. WHICH STATEMENTS BY THE CLIENT INDICATE A NEED FOR FURTHER TEACHING? (SELECT ALL THAT APPLY.) ◼ a. I should not have any problems driving to see my mother, who lives 3 hours away. ◼ b. Now that I have time off from work, I can return to my exercise routine next week. ◼ c. My granddaughter weighs 23 pounds, so I need to refrain from picking her up. ◼ d. I will have to limit the times that I climb our stairs at home to morning and night. ◼ e. For 1 month, I will need to refrain from sexual intercourse. ◼ ANS: A, B Driving and sitting for extended periods of time should be avoided until the surgeon gives permission. For 2 to 6 weeks, exercise participation should also be avoided. All of the other responses demonstrate adequate knowledge for discharge. The client should not lift anything heavier than 10 pounds, should limit stair climbing, and should refrain from sexual intercourse. THE NURSE IS TAKING THE HISTORY OF A 24-YEAR-OLD CLIENT DIAGNOSED WITH CERVICAL CANCER. WHAT POSSIBLE RISK FACTORS WOULD THE NURSE ASSESS? (SELECT ALL THAT APPLY.) ◼ a. Smoking ◼ b. Multiple sexual partners ◼ c. Poor diet ◼ d. Nulliparity ◼ e. Younger than 18 at first intercourse ◼ ANS: A, B, C, E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer. AN EMERGENCY ROOM NURSE ASSESSES A CLIENT AFTER A MOTOR VEHICLE CRASH AND NOTES ECCHYMOTIC AREAS ACROSS THE CLIENTS LOWER ABDOMEN. WHICH ACTION SHOULD THE NURSE TAKE FIRST? ◼ a. Measure the clients abdominal girth. ◼ b. Assess for abdominal guarding or rigidity. ◼ c. Check the clients hemoglobin and hematocrit. ◼ d. Obtain the clients complete health history. ◼ ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. AFTER TEACHING A CLIENT WITH IRRITABLE BOWEL SYNDROME (IBS), A NURSE ASSESSES THE CLIENTS UNDERSTANDING. WHICH MENU SELECTION INDICATES THAT THE CLIENT CORRECTLY UNDERSTANDS THE DIETARY TEACHING? ◼ a. Ham sandwich on white bread, cup of applesauce, glass of diet cola ◼ b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice ◼ c. Grilled cheese sandwich, small banana, cup of hot tea with lemon ◼ d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk ◼ ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. A NURSE ASSESSES CLIENTS AT A COMMUNITY HEALTH CENTER. WHICH CLIENT IS AT HIGHEST RISK FOR THE DEVELOPMENT OF COLORECTAL CANCER? ◼ a. A 37-year-old who drinks eight cups of coffee daily ◼ b. A 44-year-old with irritable bowel syndrome (IBS) ◼ c. A 60-year-old lawyer who works 65 hours per week ◼ d. A 72-year-old who eats fast food frequently ◼ ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. A NURSE ASSESSING A CLIENT WITH COLORECTAL CANCER AUSCULTATES HIGH-PITCHED BOWEL SOUNDS AND NOTES THE PRESENCE OF VISIBLE PERISTALTIC WAVES. WHICH ACTION SHOULD THE NURSE TAKE? ◼ a. Ask if the client is experiencing pain in the right shoulder. ◼ b. Perform a rectal examination and assess for polyps. ◼ c. Contact the provider and recommend computed tomography. ◼ d. Administer a laxative to increase bowel movement activity. ◼ ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client. A NURSE PREPARES A CLIENT FOR A COLONOSCOPY SCHEDULED FOR TOMORROW. THE CLIENT STATES, MY DOCTOR TOLD ME THAT THE FECAL OCCULT BLOOD TEST WAS NEGATIVE FOR COLON CANCER. I DONT THINK I NEED THE COLONOSCOPY AND WOULD LIKE TO CANCEL IT. HOW SHOULD THE NURSE RESPOND? ◼ a. Your doctor should not have given you that information prior to the colonoscopy. ◼ b. The colonoscopy is required due to the high percentage of false negatives with the blood test. ◼ c. A negative fecal occult blood test does not rule out the possibility of colon cancer. ◼ d. I will contact your doctor so that you can discuss your concerns about the procedure. ◼ ANS: C ◼ A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider. A NURSE CARES FOR A CLIENT NEWLY DIAGNOSED WITH COLON CANCER WHO HAS BECOME WITHDRAWN FROM FAMILY MEMBERS. WHICH ACTION SHOULD THE NURSE TAKE? ◼ a. Contact the provider and recommend a psychiatric consult for the client. ◼ b. Encourage the client to verbalize feelings about the diagnosis. ◼ c. Provide education about new treatment options with successful outcomes. ◼ d. Ask family and friends to visit the client and provide emotional support. ◼ ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the clients feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. A NURSE CARES FOR A CLIENT WITH COLON CANCER WHO HAS A NEW COLOSTOMY. THE CLIENT STATES, I THINK IT WOULD BE HELPFUL TO TALK WITH SOMEONE WHO HAS HAD A SIMILAR EXPERIENCE. HOW SHOULD THE NURSE RESPOND? ◼ a. I have a good friend with a colostomy who would be willing to talk with you. ◼ b. The enterostomal therapist will be able to answer all of your questions. ◼ c. I will make a referral to the United Ostomy Associations of America. ◼ d. You’ll find that most people with colostomies don’t want to talk about them. ◼ ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the clients request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. A NURSE CARES FOR A CLIENT WHO STATES, MY HUSBAND IS REPULSED BY MY COLOSTOMY AND REFUSES TO BE INTIMATE WITH ME. HOW SHOULD THE NURSE RESPOND? ◼ a. Lets talk to the ostomy nurse to help you and your husband work through this. ◼ b. You could try to wear longer lingerie that will better hide the ostomy appliance. ◼ c. You should empty the pouch first so it will be less noticeable for your husband. ◼ d. If you are not careful, you can hurt the stoma if you engage in sexual activity. ◼ ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. A NURSE ASSESSES A CLIENT WITH A MECHANICAL BOWEL OBSTRUCTION WHO REPORTS INTERMITTENT ABDOMINAL PAIN. AN HOUR LATER THE CLIENT REPORTS CONSTANT ABDOMINAL PAIN. WHICH ACTION SHOULD THE NURSE TAKE NEXT? ◼ a. Administer intravenous opioid medications.] ◼ b. Position the client with knees to chest. ◼ c. Insert a nasogastric tube for decompression. ◼ d. Assess the clients bowel sounds. ◼ ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. A NURSE CARES FOR A CLIENT WHO HAD A COLOSTOMY PLACED IN THE ASCENDING COLON 2 WEEKS AGO. THE CLIENT STATES, THE STOOL IN MY POUCH IS STILL LIQUID. HOW SHOULD THE NURSE RESPOND? ◼ a. The stool will always be liquid with this type of colostomy. ◼ b. Eating additional fiber will bulk up your stool and decrease diarrhea. ◼ c. Your stool will become firmer over the next couple of weeks. ◼ d. This is abnormal. I will contact your health care provider. ◼ ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time. A NURSE TEACHES A CLIENT WHO IS RECOVERING FROM A COLON RESECTION. WHICH STATEMENT SHOULD THE NURSE INCLUDE IN THIS CLIENTS PLAN OF CARE? ◼ a. You may experience nausea and vomiting for the first few weeks. ◼ b. Carbonated beverages can help decrease acid reflux from anastomosis sites. ◼ c. Take a stool softener to promote softer stools for ease of defecation. ◼ d. You may return to your normal workout schedule, including weight-lifting. ◼ ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation A NURSE TEACHES A CLIENT WHO IS AT RISK FOR COLON CANCER. WHICH DIETARY RECOMMENDATION SHOULD THE NURSE TEACH THIS CLIENT? ◼ a. Eat low-fiber and low-residual foods. ◼ b. White rice and bread are easier to digest. ◼ c. Add vegetables such as broccoli and cauliflower to your new diet. ◼ d. Foods high in animal fat help to protect the intestinal mucosa. ◼ ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. A NURSE CARES FOR A CLIENT WHO HAS A NEW COLOSTOMY. WHICH ACTION SHOULD THE NURSE TAKE? ◼ a. Empty the pouch frequently to remove excess gas collection. ◼ b. Change the ostomy pouch and wafer every morning. ◼ c. Allow the pouch to completely fill with stool prior to emptying it. ◼ d. Use surgical tape to secure the pouch and prevent leakage. ◼ ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. A NURSE CARES FOR A CLIENT WHO HAS A FAMILY HISTORY OF COLON CANCER. THE CLIENT STATES, MY FATHER AND MY BROTHER HAD COLON CANCER. WHAT IS THE CHANCE THAT I WILL GET CANCER? HOW SHOULD THE NURSE RESPOND? ◼ a. If you eat a low-fat and low-fiber diet, your chances decrease significantly. ◼ b. You are safe. This is an autosomal dominant disorder that skips generations. ◼ c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. ◼ d. You should have a colonoscopy more frequently to identify abnormal polyps early. ◼ ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the clients diet, preemptive chemotherapy, and removal of polyps will decrease the clients risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. A NURSE INSERTS A NASOGASTRIC (NG) TUBE FOR AN ADULT CLIENT WHO HAS A BOWEL OBSTRUCTION. WHICH ACTIONS DOES THE NURSE PERFORM CORRECTLY? (SELECT ALL THAT APPLY.) ◼ a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders ◼ b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx \ ◼ c. Checks for correct placement by checking the pH of the fluid aspirated from the tube ◼ d. Secures the NG tube by taping it to the client’s nose and pinning the end to the pillowcase ◼ e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent ◼ ANS: A, C, E The clients head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate. AFTER TEACHING A CLIENT WHO IS RECOVERING FROM A COLON RESECTION, THE NURSE ASSESSES THE CLIENTS UNDERSTANDING. WHICH STATEMENTS BY THE CLIENT INDICATE A CORRECT UNDERSTANDING OF THE TEACHING? (SELECT ALL THAT APPLY.) ◼ a. I must change the ostomy appliance daily and as needed. ◼ b. I will use warm water and a soft washcloth to clean around the stoma. ◼ c. I might start bicycling and swimming again once my incision has healed. ◼ d. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown. ◼ e. I will check the stoma regularly to make sure that it stays a deep red color. ◼ f. I must avoid dairy products to reduce gas and odor in the pouch. ◼ ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the clients skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the clients skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. A NURSE PLANS CARE FOR A CLIENT WHO IS RECOVERING FROM AN INGUINAL HERNIA REPAIR. WHICH INTERVENTIONS SHOULD THE NURSE INCLUDE IN THIS CLIENTS PLAN OF CARE? (SELECT ALL THAT APPLY.) ◼ a. Encouraging ambulation three times a day ◼ b. Encouraging normal urination ◼ c. Encouraging deep breathing and coughing ◼ d. Providing ice bags and scrotal support ◼ e. Forcibly reducing the hernia ◼ ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care. A NURSE CARES FOR A CLIENT WHO HAS BEEN DIAGNOSED WITH A SMALL BOWEL OBSTRUCTION. WHICH ASSESSMENT FINDINGS SHOULD THE NURSE CORRELATE WITH THIS DIAGNOSIS? (SELECT ALL THAT APPLY.) ◼ a. Serum potassium of 2.8 mEq/L ◼ b. Loss of 15 pounds without dieting ◼ c. Abdominal pain in upper quadrants ◼ d. Low-pitched bowel sounds ◼ e. Serum sodium of 121 mEq/L ◼ ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions. A NURSE ASSESSES A MALE CLIENT WITH AN ABDOMINAL HERNIA. WHICH ABDOMINAL HERNIAS ARE CORRECTLY PAIRED WITH THEIR PHYSIOLOGIC PROCESSES? (SELECT ALL THAT APPLY.) ◼ a. Indirect inguinal hernia An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac ◼ b. Femoral hernia A peritoneum sac pushes downward and may descend into the scrotum ◼ c. Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall ◼ d. Ventral hernia Results from inadequate healing of an incision ◼ e. Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity ◼ ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac. A NURSE CARES FOR A CLIENT WHO HAS OBSTRUCTIVE JAUNDICE. THE CLIENT ASKS, WHY IS MY SKIN SO ITCHY? HOW SHOULD THE NURSE RESPOND? ◼ a. Bile salts accumulate in the skin and cause the itching. ◼ b. Toxins released from an inflamed gallbladder lead to itching. ◼ c. Itching is caused by the release of calcium into the skin. ◼ d. Itching is caused by a hypersensitivity reaction. ◼ ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate. AFTER TEACHING A CLIENT WHO IS RECOVERING FROM LAPAROSCOPIC CHOLECYSTECTOMY SURGERY, THE NURSE ASSESSES THE CLIENTS UNDERSTANDING. WHICH STATEMENT MADE BY THE CLIENT INDICATES A CORRECT UNDERSTANDING OF THE TEACHING? ◼ a. Drinking at least 2 liters of water each day is suggested. ◼ b. I will decrease the amount of fatty foods in my diet. ◼ c. Drinking fluids with my meals will increase bloating. ◼ d. I will avoid concentrated sweets and simple carbohydrates. ◼ ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required. A NURSE CARES FOR A CLIENT WHO IS RECOVERING FROM LAPAROSCOPIC CHOLECYSTECTOMY SURGERY. THE CLIENT REPORTS PAIN IN THE SHOULDER BLADES. HOW SHOULD THE NURSE RESPOND? ◼ a. Ambulating in the hallway twice a day will help. ◼ b. I will apply a cold compress to the painful area on your back. ◼ c. Drinking a warm beverage can relieve this referred pain. ◼ d. You should cough and deep breathe every hour. ◼ ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide. AFTER TEACHING A CLIENT WHO HAS A HISTORY OF CHOLELITHIASIS, THE NURSE ASSESSES THE CLIENTS UNDERSTANDING. WHICH MENU SELECTION MADE BY THE CLIENT INDICATES THE CLIENT CLEARLY UNDERSTANDS THE DIETARY TEACHING? ◼ a. Lasagna, tossed salad with Italian dressing, and low-fat milk ◼ b. Grilled cheese sandwich, tomato soup, and coffee with cream ◼ c. Cream of potato soup, Caesar salad with chicken, and a diet cola ◼ d. Roasted chicken breast, baked potato with chives, and orange juice ◼ ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner. A NURSE PLANS CARE FOR A CLIENT WITH ACUTE PANCREATITIS. WHICH INTERVENTION SHOULD THE NURSE INCLUDE IN THIS CLIENTS PLAN OF CARE TO REDUCE DISCOMFORT? ◼ a. Administer morphine sulfate intravenously every 4 hours as needed. ◼ b. Maintain nothing by mouth (NPO) and administer intravenous fluids. ◼ c. Provide small, frequent feedings with no concentrated sweets. ◼ d. Place the client in semi-Fowlers position with the head of bed elevated. ◼ ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort. A NURSE ASSESSES A CLIENT WHO HAS CHOLECYSTITIS. WHICH CLINICAL MANIFESTATION INDICATES THAT THE CONDITION IS CHRONIC RATHER THAN ACUTE? ◼ a. Temperature of 100.1 F (37.8 C) ◼ b. Positive Murphys sign ◼ c. Light-colored stools ◼ d. Upper abdominal pain after eating ◼ ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis. A NURSE CARES FOR A CLIENT WHO IS PRESCRIBED PATIENT-CONTROLLED ANALGESIA (PCA) AFTER A CHOLECYSTECTOMY. THE CLIENT STATES, WHEN I WAKE UP I AM IN PAIN. WHICH ACTION SHOULD THE NURSE TAKE? ◼ a. Administer intravenous morphine while the client sleeps. ◼ b. Encourage the client to use the PCA pump upon awakening. ◼ c. Contact the provider and request a different analgesic. ◼ d. Ask a family member to initiate the PCA pump for the client. ◼ ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump. A NURSE ASSESSES A CLIENT WITH CHOLELITHIASIS. WHICH ASSESSMENT FINDINGS SHOULD THE NURSE IDENTIFY AS CONTRIBUTORS TO THIS CLIENTS CONDITION? (SELECT ALL THAT APPLY.) ◼ a. Body mass index of 46 ◼ b. Vegetarian diet ◼ c. Drinking 4 ounces of red wine nightly ◼ d. Pregnant with twins ◼ e. History of metabolic syndrome ◼ f. Glycosylated hemoglobin level of 15% ◼ ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection. THE NURSE IS CONDUCTING A HISTORY ON A MALE CLIENT TO DETERMINE THE SEVERITY OF SYMPTOMS ASSOCIATED WITH PROSTATE ENLARGEMENT. WHICH FINDING IS CAUSE FOR PROMPT ACTION BY THE NURSE? ◼ a. Cloudy urine ◼ b. Urinary hesitancy ◼ c. Post-void dribbling ◼ d. Weak urinary stream ◼ ANS: A ◼ Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction. A CLIENT IS DIAGNOSED WITH BENIGN PROSTATIC HYPERPLASIA AND SEEMS SAD AND IRRITABLE. AFTER ASSESSING THE CLIENTS BEHAVIOR, WHICH STATEMENT BY THE NURSE WOULD BE THE MOST APPROPRIATE? ◼ a. The urine incontinence should not prevent you from socializing. ◼ b. You seem depressed and should seek more pleasant things to do. ◼ c. It is common for men at your age to have changes in mood. ◼ d. Nocturia could cause interruption of your sleep and cause changes in mood. ◼ ANS: D ◼ Frequent visits to the bathroom during the night could cause sleep interruptions and affect the clients mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity. A 55-YEAR-OLD AFRICAN-AMERICAN CLIENT IS HAVING A VISIT WITH HIS HEALTH CARE PROVIDER. WHAT TEST SHOULD THE NURSE DISCUSS WITH THE CLIENT AS AN OPTION TO SCREEN FOR PROSTATE CANCER, EVEN THOUGH SCREENING IS NOT ROUTINELY RECOMMENDED? ◼ a. Complete blood count ◼ b. Culture and sensitivity ◼ c. Prostate-specific antigen ◼ d. Cystoscopy ◼ ANS: C ◼ The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction. THE NURSE IS TEACHING A CLIENT WITH BENIGN PROSTATIC HYPERPLASIA (BPH). WHAT STATEMENT INDICATES A LACK OF UNDERSTANDING BY THE CLIENT? ◼ a. There should be no problem with a glass of wine with dinner each night. ◼ b. I am so glad that I weaned myself off of coffee about a year ago. ◼ c. I need to inform my allergist that I cannot take my normal decongestant. ◼ d. My normal routine of drinking a quart of water during exercise needs to change. ◼ ANS: A ◼ This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention. A CLIENT HAS RETURNED FROM A TRANSURETHRAL RESECTION OF THE PROSTATE WITH A CONTINUOUS BLADDER IRRIGATION. WHICH ACTION BY THE NURSE IS A PRIORITY IF BRIGHT RED URINARY DRAINAGE AND CLOTS ARE NOTED 5 HOURS AFTER THE SURGERY? ◼ a. Review the hemoglobin and hematocrit as ordered. ◼ b. Take vital signs and notify the surgeon immediately. ◼ c. Release the traction on the three-way catheter. ◼ d. Remind the client not to pull on the catheter. ◼ ANS: B ◼ Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time. A 55-YEAR-OLD MALE CLIENT IS ADMITTED TO THE EMERGENCY DEPARTMENT WITH SYMPTOMS OF A MYOCARDIAL INFARCTION. WHICH QUESTION BY THE NURSE IS THE MOST APPROPRIATE BEFORE ADMINISTERING NITROGLYCERIN? ◼ a. On a scale from 0 to 10, what is the rating of your chest pain? ◼ b. Are you allergic to any food or medications? ◼ c. Have you taken any drugs like Viagra recently? ◼ d. Are you light-headed or dizzy right now? ◼ ANS: C ◼ Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin. THE NURSE IS TEACHING AN UNCIRCUMCISED 65-YEAR-OLD CLIENT ABOUT SELF-MANAGEMENT OF A URINARY CATHETER IN PREPARATION FOR DISCHARGE TO HIS HOME. WHAT STATEMENT INDICATES A LACK OF UNDERSTANDING BY THE CLIENT? ◼ a. I only have to wash the outside of the catheter once a week. ◼ b. I should take extra time to clean the catheter site by pushing the foreskin back. ◼ c. The drainage bag needs to be changed at least once a week and as needed. ◼ d. I should pour a solution of vinegar and water through the tubing and bag. ◼ ANS: A ◼ The first few inches of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting. A CLIENT IS INTERESTED IN LEARNING ABOUT THE RISK FACTORS FOR PROSTATE CANCER. WHICH FACTORS DOES THE NURSE INCLUDE IN THE TEACHING? (SELECT ALL THAT APPLY.) ◼ a. Family history of prostate cancer ◼ b. Smoking ◼ c. Obesity ◼ d. Advanced age ◼ e. Eating too much red meat ◼ f. Race ◼ ANS: A, D, E, F ◼ Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors. A CLIENT CAME TO THE CLINIC WITH ERECTILE DYSFUNCTION. WHAT ARE SOME POSSIBLE CAUSES OF THIS CONDITION THAT THE NURSE COULD DISCUSS WITH THE CLIENT DURING HISTORY TAKING? (SELECT ALL THAT APPLY.) ◼ a. Recent prostatectomy ◼ b. Long-term hypertension ◼ c. Diabetes mellitus ◼ d. Hour-long exercise sessions ◼ e. Consumption of beer each night ◼ ANS: A, B, C, E ◼ Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.