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A 60-year-old client has undergone a nerve-sparing prostatectomy and has been advised by his physician that he may not recover normal sexual functioning. The client is very concerned about this and asks the nurse for more information. Which of the following information should the nurse include? Select all that apply.
A. Retrograde ejaculation may occur.
B. Recovery rates vary but can take up to a year or more.
C. If sexual functioning is going to return, it will do so within a month.
D. Attempts at sexual intercourse are usually avoided for 1 month after surgery.
E. Anxiety can interfere with sexual functioning.
F. Other forms of sexual intimacy are more important than sexual intercourse.
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
A. Gingival hypertrophy
B. Hirsutism
C. Hypertrophy of facial subcutaneous tissue
D. Dementia
E. Anemia
A client is hospitalized in a long-term care facility because of Alzheimer's disease. The client is incontinent of urine and feces. The nurse has delegated incontinent care to unlicensed assistive personnel (UAP). How frequently should the nurse advice that the UAP check the client for dryness?
A. Every 2 hours
B. Every hour
C. When the client appears restless
D. Before meals and at bedtime
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypertensive with a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions should the nurse anticipate? Select all that apply
A. Immediately stop the infusion.
B. Discontinue the PCA pump.
C. Administer naloxone per standing orders.
D. Administer supplementary oxygen.
E. File an incident report.
If teaching a client to use a metered-dose inhaler (MDI) without a spacer, how far away from the mouth should the nurse advise the client that the inhaler be positioned when administering a dose of inhaled medication?
A. The inhaler should be enclosed within the clients’ lips.
B. The inhaler should be immediately outside of the client's lips.
C. The inhaler should be 1-2 inches away from the client's lips.
D. The inhaler should be 3—4 inches away from the client's lips.
Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?
A. 4-6 hours
B. 8—12 hours
C. 24 hours
D. 36 hours
If a six-year-old child has influenza with a fever and cough, which statements by the child's caregiver suggest a need for education? Select all that apply
A. "If his fever gets too high, I'll give him a bath in cold water."
B. "I try to offer him plenty of liquids."
C. "Sipping hot lemonade seems to help relieve his cough."
D. "I've been giving him baby aspirin to lower his fever."
E. "I alternate giving him acetaminophen and ibuprofen for this fever."
A client has an open draining wound infected with MRSA and is on contact precautions. If the nurse is entering the room to care for the client, when are gloving and gowning necessary?
A. When the nurse has direct contact with the wound or drainage
B. When the nurse has direct contact with the clients’ body, wound, or drainage
C. When the nurse enters the room for any type of patient or environmental contact
D. When drainage is not contained by a dressing
A neonate has severe congenital abnormalities that make death imminent. The NICU team believes that further attempts at treatment or feeding are not warranted and that palliative care only should be provided, When speaking with the parents about this, which of the following is the best approach?
A. Tell the parents that the team suggests that all food and treatment will be withheld.
B. Tell the parents that the team suggests a change in care plan to focus on comfort measures.
C. Tell the parents that any further efforts at treatment are futile, as the infant is dying.
D. Tell the parents that the best thing is to let nature take its course.
A client has increasing pain in both hands. On examination, the nurse notes that the metatarsophalangeal and proximal interphalangeal joints are enlarged and swollen, swan-neck deformity is evident, and the fingers on both hands show ulnar deviation. These findings are consistent with which of the following disorders?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Gouty arthritis
D. Psoriatic arthritis