The nurse is caring for a client diagnosed with leukemia who has just completed a course of radiation therapy and chemotherapy in preparation for a bone marrow transplant. The nurse notices that the client is febrile, has foul smelling urine, and is complaining of urinary frequency and dysuria. What is the priority nursing action?

Request medical prescription for an antibiotic such as gentamicin

Obtain a full set of vital signs and have the client void in a specimen cup

Increase intake of oral fluids such as cranberry juice

Place the client in protective isolation

Answer and Explanation

The Correct Answer is B

A.   While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B.   This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C.   While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D.   Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

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Correct Answer is A

Explanation

A. Using adaptive equipment suggests they are finding ways to maintain independence and complete activities of daily living (ADLs) despite any physical or cognitive limitations. This is a positive sign of adaptation.
B. Difficulty using modified feeding utensils suggests that the client is struggling to adapt to the changes caused by the stroke. If they cannot use these utensils effectively, it indicates a challenge in managing their eating independently, which is not a sign of successful adaptation.
C. While emotional responses like depression and irritability are common after a stroke, experiencing these feelings frequently can indicate difficulty in coping with the changes. This does not reflect successful adaptation; rather, it suggests that the client may be struggling emotionally and psychologically with their new circumstances.
D. While frustration can be a normal response to challenges after a stroke, particularly in the context of regaining independence, getting angry at family members may indicate difficulty in coping with the changes or an inability to manage frustration.

A. Utilizing hormone replacement therapy B. Yearly colposcopy testing C. Utilizing safer sex methods D. Vaginal ultrasound every 2 years

Correct Answer is C

Explanation

A. This choice is not relevant to reducing the risk of cervical cancer. Hormone replacement therapy (HRT) is primarily used to manage symptoms of menopause and does not have a protective effect against cervical cancer.
B. While colposcopy is a diagnostic procedure used to evaluate abnormal cervical findings, it is not a routine screening method. The primary screening method for cervical cancer is the Pap test (Papanicolaou test) combined with HPV (human papillomavirus) testing. Colposcopy is usually performed after an abnormal Pap test result, not on a yearly basis for general screening.
C. Utilizing safer sex methods, such as consistent use of condoms and reducing the number of sexual partners, can help decrease the risk of acquiring HPV, which is the primary cause of cervical cancer. Promoting safe sexual practices is a key component of cervical cancer prevention.
D. This choice is not effective for reducing the risk of cervical cancer. While vaginal ultrasounds may be used for various gynecological assessments, they are not a screening tool for cervical cancer and do not reduce the risk of developing the disease.

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Naxlex Comprehensive Predictor Exams

The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

Correct Answer is A

Explanation

Which one of the following topics should the nurse include in a community health promotion seminar to illustrate ways to reduce the risk of cervical cancer?

Correct Answer is C

Explanation

The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?

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The nurse is performing a health screening of a 37-year-old female client. Which factor(s) would alert the nurse that this client is at greatest risk for developing a stroke?

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