GCC 601 - 625

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). The nurse educates the client that spermicidal agents:

• Are also effective in reducing vaginal fungal infections such as Candida albicans.
• Eliminate bacterial and viral STIs.
• Are more effective when used in conjunction with barrier methods, such as the diaphragm or condom.
• Are used on an "as-needed" basis and exhibit few side effects.
• -

Answer explanation

Option 1: Are also effective in reducing vaginal fungal infections such as Candida albicans.

Option 2: Eliminate bacterial and viral STIs.

Option 3: Are more effective when used in conjunction with barrier methods, such as the diaphragm or condom.

Option 4: Are used on an "as-needed" basis and exhibit few side effects.

Option 5: -

Correct Option: Option 3 – Are more effective when used in conjunction with barrier methods, such as the diaphragm or condom.

Explanation: Spermicidal agents alone have an approximately 25% failure rate in preventing pregnancy. These agents (nonoxynol 9 and octoxynol) kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. They have some cidal effect on viruses in vitro but need to be studied in vivo. They do not kill fungi such as Candida albicans, even in high concentrations. Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections.

Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance in an 80-year-old client being admitted to a nursing home?

• My skin is always so dry.
• I often use a laxative for constipation.
• I have always liked to drink a lot of water.
• I sometimes have a problem with dribbling urine.
• -

Answer explanation

Option 1: My skin is always so dry.

Option 2: I often use a laxative for constipation.

Option 3: I have always liked to drink a lot of water.

Option 4: I sometimes have a problem with dribbling urine.

Option 5: -

Correct Option: Option 2 – I often use a laxative for constipation.

Explanation: The misuse and overuse of laxatives can cause serious fluid and electrolyte imbalances in the elderly, so this is the correct choice. Answers A and D can be normal occurrences associated with the physiological changes of aging. Answer C is an incorrect response because the client states that increased fluid intake is not a new occurrence.

A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:

• Remove the unsightly markings with acetone or alcohol
• Cover the radiation site with loose gauze dressing
• Sprinkle baby powder over the radiated area
• Refrain from using soap or lotion on the marked area
• -

Answer explanation

Option 1: Remove the unsightly markings with acetone or alcohol

Option 2: Cover the radiation site with loose gauze dressing

Option 3: Sprinkle baby powder over the radiated area

Option 4: Refrain from using soap or lotion on the marked area

Option 5: -

Correct Option: Option 4 – Refrain from using soap or lotion on the marked area

Explanation: The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect.

While assessing a patient's heart sounds, the nurse hears a murmur at the second left intercostal space along the left sternal border. Which valve is most likely involved?

• Aortic
• Mitral
• Pulmonic
• Tricuspid
• -

Answer explanation

Option 1: Aortic

Option 2: Mitral

Option 3: Pulmonic

Option 4: Tricuspid

Option 5: -

Correct Option: Option 3 – Pulmonic

Explanation: Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Abnormalities of the aortic valve (Option A) are heard at the second intercostal space to the right of the sternum; of the mitral valve (Option B), at the fifth intercostal space in the midclavicular line; and of the tricuspid valve (Option D), at the third and fourth intercostal spaces along the sternal border.

Which form of therapy uses radiation to kill cancerous cells?

• Chemotherapy.
• Chirotherapy.
• Radiotherapy.
• Ultratherapy.
• -

Answer explanation

Option 1: Chemotherapy.

Option 2: Chirotherapy.

Option 3: Radiotherapy.

Option 4: Ultratherapy.

Option 5: -

Correct Option: Option 3 – Radiotherapy.

Explanation: Radiotherapy is the use of radiation to kill cancerous cells. Radiation works by destroying malignant cells or stopping cell growth. It is most effective in treating localized cancer masses. Unfortunately, in the process of destroying malignant cells, radiotherapy also destroys some healthy cells. It may also increase the risk for other types of cancer.

Which exam is most reliable in diagnosing peptic ulcer disease?

• Upper-gastrointestinal x-ray
• Gastric analysis
• Endoscopy
• Barium studies
• -

Answer explanation

Option 1: Upper-gastrointestinal x-ray

Option 2: Gastric analysis

Option 3: Endoscopy

Option 4: Barium studies

Option 5: -

Correct Option: Option 3 – Endoscopy

Explanation: Although all of the tests listed can be used to diagnose an ulcer, an endoscopic exam is the only way to obtain accurate visual evidence. Answers A, B, and D are not as accurate or reliable, which makes them incorrect.

Which action is included in the principles of asepsis?

• Maintaining a sterile environment
• Keeping the environment as clean as possible
• Testing for microorganisms in the environment
• Cleaning an environment until it is free from germs
• -

Answer explanation

Option 1: Maintaining a sterile environment

Option 2: Keeping the environment as clean as possible

Option 3: Testing for microorganisms in the environment

Option 4: Cleaning an environment until it is free from germs

Option 5: -

Correct Option: Option 2 – Keeping the environment as clean as possible

Explanation: Asepsis is the process of avoiding contamination from outside sources by keeping the environment clean. A clean environment has a reduced number of microorganisms, but isn't necessarily sterile (the absence of all microorganisms) (Option A). Testing for microorganisms or culturing (Option C) isn't indicated for asepsis. Cleaning an environment until it is free from germs (Option D) would result in a sterile environment.

The nurse cares for a client who returns from a cystoscopy. The nurse knows that which assessment finding is within normal limits for this client?

• Blood-tinged urine.
• Decreased urine output.
• Severe abdominal or pelvic pain.
• Fever.
• -

Answer explanation

Option 1: Blood-tinged urine.

Option 2: Decreased urine output.

Option 3: Severe abdominal or pelvic pain.

Option 4: Fever.

Option 5: -

Correct Option: Option 1 – Blood-tinged urine.

Explanation: During a cystoscopy, a cystoscope is used to directly visualize the bladder and urethra. The nurse should expect the appearance of blood-tinged urine after this invasive procedure. The nurse should be concerned if the following abnormal assessment findings appeared: decreased urine output (indicates blockage), abdominal or pelvic pain (indicates substantial trauma to urinary structures), or fever (indicates infection secondary to the invasive procedure).

The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is:

• To treat general discomfort
• To correct electrolyte imbalances
• To prevent stress ulcers
• To treat nausea
• -

Answer explanation

Option 1: To treat general discomfort

Option 2: To correct electrolyte imbalances

Option 3: To prevent stress ulcers

Option 4: To treat nausea

Option 5: -

Correct Option: Option 3 – To prevent stress ulcers

Explanation: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect.

A 33-year-old patient undergoes an L4-L5 laminectomy. Which of the following would work best to prevent postoperative complications?

• Encouraging the patient to be out of bed the first postoperative day
• Maximizing bracing while in bed
• Limiting movement in bed and repositioning only when necessary
• Using a soft mattress
• -

Answer explanation

Option 1: Encouraging the patient to be out of bed the first postoperative day

Option 2: Maximizing bracing while in bed

Option 3: Limiting movement in bed and repositioning only when necessary

Option 4: Using a soft mattress

Option 5: -

Correct Option: Option 1 – Encouraging the patient to be out of bed the first postoperative day

Explanation: In most cases, patients should be out of bed the first postoperative day. Using a chairlike brace for the lower back when out of bed rather than maximizing bracing while in bed (Option B), frequent repositioning rather than limiting movement (Option C), and using a firm rather than soft mattress (Option D) helps to minimize complications.