The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA) on admission. The family member requests to bring in a razor for the client to use. Which response from the family would indicate an understanding teaching related to t-PA? The family member states, "I will

be careful with the straight razor."

insist the nurse use multiple razor blades."

bring in an electric razor for nurse to use for shaving."

bring in disposable razors blades to use for, shaving."

Answer and Explanation

The Correct Answer is C

A.   This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B.   This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C.   This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D.   While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Renal cancer can often present with a palpable flank mass due to tumor growth. Hematuria (blood in the urine) is also a common finding in patients with kidney tumors and can result from bleeding within the renal system. Flank pain, especially in the context of renal cancer, often accompanies these findings.
B. Dark, tarry stools (melena) suggest gastrointestinal bleeding, which is not directly associated with renal cancer. Mental status changes could indicate various issues, such as metabolic imbalances or anemia, but they are not specific findings for renal cancer.
C. While patients with advanced cancer may experience shortness of breath due to metastasis to the lungs or other complications, chest pain is not a direct finding associated with renal cancer. These symptoms could indicate other issues, such as cardiac or pulmonary problems.
D. While urinary frequency can occur due to various urinary tract issues, it is not a classic symptom of renal cancer. Hypotension is also not a typical finding associated with renal cancer unless there is significant blood loss or other complications.

A. changing the surgical dressing when it becomes saturated with drainage. B. encouraging the client to obtain permanent breast prosthesis as soon as she is discharged from the hospital. C. placing a limb alert bracelet on the right wrist as warning against blood pressure or venipunctures. D. teaching the client to use the prescribed patient-controlled analgesia (PCA) every 20 mintues for the best pain relief.

Correct Answer is C

Explanation

A. While it's important to monitor the surgical dressing, changing it too frequently can increase the risk of infection and disrupt healing. Instead, nurses typically assess the dressing regularly and only change it if it's overly saturated or if ordered by a physician. It’s essential to follow specific protocols regarding dressing changes.
B. A While breast prostheses can be an important part of post-mastectomy care for some clients, it is usually recommended that clients wait until they have fully healed and received counseling regarding their options. Immediate encouragement may be premature, as physical and emotional adjustments take time after surgery.
C. This is an appropriate intervention. After axillary lymph node dissection, there is a risk of lymphedema in the affected arm. Placing a limb alert bracelet serves as a reminder to healthcare providers to avoid taking blood pressure or performing venipunctures on the affected arm, thus helping prevent complications.
D. While PCA can be an effective method for managing postoperative pain, the timing and dosage should be based on the specific prescription and the client's individual needs. It’s crucial to educate the client about the PCA device and its use, but the specific interval may vary based on the medication's parameters and the patient's condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with renal cancer. The client is complaining of flank pain. Which additional assessment finding should the nurse expect?

Correct Answer is A

Explanation

A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:

Correct Answer is C

Explanation

The nurse is caring for a client that has undergone a modified left radical mastectomy with lymph node removal. Which intervention would assist in preventing lymphedema?

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?

A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?

A client has a radiation implant inserted for treatment of cervical cancer. Which nurse should be assigned to provide personal care while the radiation source is in the client? The:

The client is admitted with complaints of photosensitivity, neck stiffness, and a "thunderclap" headache. The nurse recognizes that these clinical manifestations would present with which type of stroke?

A client's Pap test reveals cervical cells with dysplasia changes. The nurse understands that information obtained during the client's health history and identified as a major risk factor for cervical cancer is:

The nurse is teaching a client about early detection for penile cancer. The nurse knows the teaching is effective when the client states, "I will:

A nurse is caring for a 58-year-old client who is diagnosed with uterine cancer. Which of the following manifestations is likely to be reported by this client?