Question

A nurse is caring for a client at an outpatient clinic.

Answer 1

Correct Answers:

Weight
Frequency of bowel movements
Hemoglobin
Stool color
Pain
Blood pressure

Rationale :

Weight

🔷 The client’s weight dropped from 112.7 kg (248 lb) to 110 kg (220 lb), which is a significant unintentional weight loss.

🔷 Unplanned weight loss in an older adult raises concern for malignancy or chronic GI disease progression.

🔷 In the context of ribbon-like stools and dark stools, weight loss strengthens suspicion for a possible colonic mass or GI bleeding source.

🔷 Weight trends help the provider assess nutritional decline and severity of illness.

🔷 Reporting this supports urgent evaluation and expedited diagnostic workup.

Frequency of bowel movements

🔷 The client reports no bowel movement for 4 days with ongoing constipation and abdominal distention.

🔷 Persistent constipation with new stool caliber changes (ribbon-like) is concerning for bowel obstruction or colon tumor.

🔷 Hypoactive bowel sounds and distention suggest slowed GI motility that may be worsening.

🔷 This pattern requires prompt provider assessment to prevent complications like impaction or obstruction.

🔷 Reporting frequency changes helps guide urgent imaging, GI referral, and interventions.

Hemoglobin

🔷 The hemoglobin dropped sharply from 12.5 g/dL to 7.5 g/dL, indicating severe anemia.

🔷 This degree of anemia can cause fatigue, tachycardia, and shortness of breath, which the client is demonstrating.

🔷 Such a rapid decline strongly suggests active or chronic blood loss, especially with dark stools.

🔷 A hemoglobin this low may require urgent management such as type and screen, iron studies, transfusion evaluation, and investigation for bleeding.

🔷 Immediate reporting is critical because it represents a high-risk, potentially unstable condition.

Stool color

🔷 The client reports stools that are dark brown to black, which can indicate melena (upper GI bleeding) or significant GI blood loss.

🔷 In combination with severe anemia (Hgb 7.5), stool color strongly supports a bleeding source.

🔷 The stool is also described as ribbon-like, which increases concern for a colonic narrowing/mass.

🔷 Stool color changes are a key red-flag symptom that requires prompt diagnostic evaluation.

🔷 Reporting this helps prioritize urgent testing such as fecal occult blood, colonoscopy planning, and stabilization.

Pain

🔷 The client now reports abdominal pain (4/10) with distention and chronic constipation.

🔷 New or worsening abdominal pain with altered stool caliber can indicate obstruction, inflammation, or malignancy-related narrowing.

🔷 Pain plus hypoactive bowel sounds suggests decreased GI movement and possible progression of a serious condition.

🔷 In an older adult with ulcerative colitis and family history of colon cancer, abdominal pain warrants urgent escalation.

🔷 Reporting pain supports timely imaging and GI evaluation to prevent deterioration.

Blood pressure

🔷 The blood pressure is 88/58 mm Hg, which is hypotension and clinically significant.

🔷 Hypotension with tachycardia (108/min) and low hemoglobin suggests possible hemodynamic compromise from blood loss.

🔷 This combination indicates reduced oxygen delivery and risk of shock, especially in an older adult.

🔷 Immediate reporting allows rapid intervention (IV access, fluids, further labs, possible transfer).

🔷 This is a priority red flag because it signals potential instability.

Potassium

🔷Potassium is 3.5 mEq/L, which is within the expected reference range (low-normal) and not the most urgent abnormality.

🔷 It should be monitored, but it does not explain the severe anemia and hypotension requiring immediate escalation.

Blood glucose

🔷 Glucose is 110 mg/dL, only slightly above the reference range and not an immediate threat compared with hypotension and hemoglobin decline.

🔷 The current urgent concern is potential GI bleeding/colon pathology, not acute glucose instability.

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Answer 2

Correct Answers:

Impaction

Rationale :

🔶 Opioids slow GI peristalsis by decreasing intestinal motility, which strongly increases constipation risk.

🔶 When a client is unable to perform most physical activity, reduced movement further worsens bowel motility.

🔶 Over time, retained stool becomes dry and hard, leading to fecal impaction.

🔶 Impaction can cause abdominal distention, pain, nausea, and even paradoxical seepage around the blockage.

🔶 For palliative clients on opioids, prevention with bowel regimen + hydration (as tolerated) is a key nursing priority.

Mucositis

🔶 This is most commonly associated with chemotherapy/radiation, not opioids.

🔶 Opioids do not directly damage oral mucosa.

Diarrhea

🔶 Opioids typically cause constipation, not diarrhea.

🔶 Diarrhea is more likely with infections, enteral feeds, or some chemo agents.

Bleeding

🔶 Opioids do not usually cause bleeding as an expected effect.

🔶 Bleeding is more consistent with thrombocytopenia, GI lesions, or anticoagulants.

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Answer 3

Correct Answers:

Penile implant
Pelvic floor physical therapy
Vacuum devices

Rationale :

Penile implant

🔷 A penile implant is a reliable option for erectile dysfunction when conservative therapies are ineffective.

🔷 It directly restores the ability to achieve an erection by providing mechanical rigidity.

🔷 This option is especially useful after prostate surgery when nerve pathways or vascular responses are impaired.

🔷 Implants can improve sexual function, confidence, and quality of life when ED persists long-term.

🔷 The client must receive teaching on surgical risks, infection prevention, and device operation.

Pelvic floor physical therapy

🔷 Pelvic floor therapy strengthens pelvic musculature (including muscles involved in erectile function and continence).

🔷 After prostate surgery, improving pelvic floor control supports better blood flow mechanics and muscle coordination during arousal.

🔷 It can also improve urinary continence, which often contributes to sexual confidence and performance.

🔷 This is a noninvasive therapy that may be part of penile rehabilitation early after surgery.

🔷 Consistent exercises (e.g., Kegels) can gradually improve function and reduce ED-related distress.

Vacuum devices

🔷 Vacuum erection devices draw blood into the penis using negative pressure, producing an erection mechanically.

🔷 They are useful after prostate surgery because they do not depend fully on nerve integrity.

🔷 Regular use may help maintain penile tissue oxygenation and reduce tissue changes associated with prolonged ED.

🔷 These devices can be used alone or with other therapies as part of a structured rehabilitation plan.

🔷 Teaching should include proper sizing and safe use of the constriction ring to prevent skin injury or impaired circulation.

Prescription for alpha blockers

🔷 Alpha blockers primarily treat urinary symptoms (e.g., BPH) by relaxing smooth muscle in the bladder neck and prostate.

🔷 They do not treat erectile dysfunction after prostate surgery and can sometimes cause dizziness/hypotension, which may complicate recovery.

Indwelling urinary catheter

🔷 An indwelling catheter is used for urinary drainage and postoperative bladder management, not erectile function.

🔷 It does not improve erections and may increase risk for UTI and discomfort if used unnecessarily.

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Answer 4

Correct Answers:

Blood in the urine or semen

Rationale :

🟦 As prostate cancer progresses, local tissue involvement can irritate or invade nearby structures, causing hematuria or blood in semen.

🟦 This finding is clinically significant because it may reflect worsening local disease or urinary tract involvement.

🟦 It also warrants prompt evaluation for obstruction, infection, or tumor-related bleeding.

🟦 In prostate cancer, urinary/ejaculatory changes are key symptoms nurses should recognize as concerning.

🟦 Reporting and follow-up supports timely staging workup and treatment planning.

A dark-colored or elevated lesion

🟦This description fits skin cancer (e.g., melanoma), not prostate cancer.

🟦It is unrelated to prostate tumor progression.

An enlarged liver or gallbladder

🟦This points more toward hepatic/biliary disease, not typical prostate cancer progression findings.

🟦Prostate cancer more commonly spreads to bone rather than causing gallbladder enlargement.

Anemia due to long-term bleeding

🟦Anemia can occur, but “long-term bleeding” is not a classic hallmark of advancing prostate cancer in this context.

🟦The more direct and expected manifestation from the options is blood in urine or semen.

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Answer 5

Correct Answers:

Pair of chemotherapy gloves

Rationale :

🟣 Oral chemotherapy is considered hazardous medication, and tablets/capsules can expose skin to drug residue.

🟣 Wearing chemotherapy-rated gloves protects the nurse from absorption and contamination during handling and administration.

🟣 This reduces occupational exposure risk, especially if pills are crushed unintentionally or if there is residue on packaging.

🟣 Gloves are a standard safety measure under hazardous drug handling precautions.

🟣 Safe handling protects both staff and the environment from cytotoxic exposure.

Specialized chemotherapy mask

🟣 Masks are mainly required when there is risk of aerosolization (e.g., powder, splashes) rather than routine oral administration.

🟣 Standard oral dosing typically prioritizes gloves first.

Face shield

🟣 A face shield is used when splash risk is high, such as handling liquid chemo or cleaning spills.

🟣 It is not routinely required for simple oral administration.

Chemotherapy gown

🟣Gowns may be needed if there’s risk of contamination (spills, crushing, body fluid exposure), but the essential baseline for oral chemo is chemo gloves.

🟣The question asks what “should occur,” making gloves the best answer.

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Answer 6

Correct Answers:

10

Rationale :

✍️Ordered dose = hydrocodone 5 mg.

✍️Available concentration = 7.5 mg per 15 mL.

✍️ Set up ratio: 5 mg/7.5 mg×15 mL

✍️ Compute: 5/7.5=0.6667; 0.6667×15

➡️ 10 mL

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Answer 7

Correct Answers:

"Clinical death can be restored by CPR."

Rationale :

🌟 Clinical death refers to the absence of breathing and circulation (no pulse), which can sometimes be reversed if treated promptly.

🌟 CPR can temporarily support circulation and oxygenation while the underlying cause is corrected.

🌟 Rapid intervention improves survival because irreversible brain injury begins after several minutes without oxygen.

🌟 Brain death, in contrast, is irreversible loss of all brain function and cannot be reversed by CPR.

🌟 The statement correctly recognizes clinical death as potentially reversible.

“Brain death can be restored by CPR."

🌟Brain death is irreversible and indicates permanent loss of brain activity.

🌟CPR cannot restore brain function once brain death is declared.

“Clinical death means that the client will be on a ventilator."

🌟 Ventilator use does not define clinical death.

🌟 Clinical death is defined by no circulation and no respirations, not mechanical ventilation.

“Clinical death can’t be reversed."

🌟 Clinical death can be reversible when CPR/defibrillation and rapid treatment occur.

🌟 Irreversibility is associated with prolonged downtime or brain death, not all clinical death.

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Answer 8

Correct Answers:

The nurse should begin full cardiopulmonary resuscitation CPR immediately.

Rationale :

💫 A full code status means the team must initiate full resuscitation efforts during cardiac arrest.

💫 Cardiac arrest requires immediate action to restore perfusion to the brain and vital organs.

💫 EEG activity does not replace the need for CPR when there is no effective circulation.

💫 Delays in CPR sharply reduce survival and neurologic outcomes.

💫 Immediate high-quality CPR is the correct priority response.

Begin chest compressions but hold rescue breathing.

💫CPR for adults includes compressions with ventilation support unless otherwise directed by current protocol and situation.

💫With full code status, provide full resuscitation, not partial.

Perform a head-to-toe assessment.

💫Assessment is secondary once arrest is confirmed.

💫The priority is immediate CPR and activation of emergency response.

Hold CPR until orders are confirmed.

💫 A full code client does not require additional confirmation to begin CPR in arrest.

💫 Waiting increases risk of death and irreversible injury.

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Answer 9

Correct Answers:

"Angiography is used to see what blood vessels are supplying the tumor to assist with treatment."

Rationale :

🔶 Angiography visualizes blood vessels using contrast to map circulation patterns.

🔶 In cancer care, it can identify the vascular supply to a tumor, which helps with treatment planning.

🔶 This information supports procedures like targeted embolization or surgical planning by showing tumor perfusion.

🔶 It is a vascular imaging study, not a tissue sampling test.

🔶 The statement correctly explains angiography’s purpose in evaluating tumor blood supply.

"Angiography causes cancer cells to 'light'..."

🔶This describes imaging modalities like PET scanning where metabolic activity is highlighted, not angiography.

🔶Angiography highlights vessels, not cancer cells directly.

"Angiography collects tissue..."

🔶 Tissue collection is done through biopsy, not angiography.

🔶 Angiography is an imaging procedure using contrast.

"Angiography identifies the presence of bone tumors."

🔶Bone tumors are better evaluated with imaging like bone scan, MRI, CT, or PET depending on context.

🔶Angiography focuses on vascular structures, not primary bone tumor detection.

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Answer 10

Correct Answers:

Basic CPR with no intubation
Medications and chest compressions

Rationale :

Basic CPR with no intubation

🔷 DNI (Do Not Intubate) means the client refuses endotracheal intubation and mechanical airway placement.

🔷 DNI does not automatically mean DNR, so CPR measures may still be appropriate unless the client also has a DNR order.

🔷 The nurse should be prepared to provide basic CPR using noninvasive airway support such as a bag-valve-mask rather than inserting a breathing tube.

🔷 This supports oxygenation and circulation while respecting the client’s limitation on intubation.

🔷 Always confirm the exact order set (DNI vs DNR vs comfort measures) to match the client’s documented wishes.

Medications and chest compressions

🔷 A DNI order restricts intubation, but it can still allow full resuscitation medications and chest compressions if the client is not DNR.

🔷 In ACLS, medications (e.g., epinephrine, antiarrhythmics) can be administered during resuscitation without requiring a breathing tube.

🔷 Chest compressions are a core intervention to maintain circulation during cardiac arrest.

🔷 The nurse should prepare to implement medication administration and compressions while using noninvasive ventilation methods as needed.

🔷 The key is honoring the boundary: no invasive airway while still supporting circulation and pharmacologic resuscitation if permitted.

Ventilation with ventilator and chest compressions

🔷 A ventilator typically requires intubation (or another invasive airway), which violates a DNI directive.

🔷 Chest compressions may be allowed, but ventilator-based ventilation conflicts with the “no intubation” limitation.

Insertion of breathing tube and defibrillation

🔷 Insertion of a breathing tube is intubation and is not permitted under DNI.

🔷 Defibrillation may be allowed depending on the broader code status, but this option includes an intervention the client refuses.

Insertion of breathing tube and chest compressions

🔷 Chest compressions may be consistent with DNI if the client is not DNR, but breathing tube insertion is not.

🔷 This choice violates the central restriction of DNI: no intubation.

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QLexNursing

1 :
A nurse is caring for a client at an outpatient clinic.

Answer Options

2 :
A nurse is caring for a client who has Stage IV lung cancer and was prescribed opioid medications for pain management. The client is unable to engage in most physical activity. Which of the following manifestations should the nurse anticipate?

3 :
A nurse is caring for a client who had prostate surgery and is experiencing erectile dysfunction. Which of the following treatment options should the nurse understand can be utilized for this client? (Select all that apply.)

4 :
The nurse is caring for a client who has prostate cancer. Which of the following manifestations does the nurse attribute to advancing disease process?

5 :
A nurse is assisting with the care of a client who is receiving chemotherapy for breast cancer. Which of the following actions should the nurse understand should occur during administration of oral chemotherapy?

7 :
A nurse is reinforcing teaching given to a client regarding the difference between brain death and clinical death. Which client statement indicates accurate understanding?

8 :
A nurse is providing care to a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

9 :
A nurse is reinforcing teaching to a client who has cancer about angiography. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is providing care to a client who states, "l have a DNI status." Which of the following interventions should the nurse be prepared to administer to the client? Select all that apply.

QLexNursing

1 : A nurse is caring for a client at an outpatient clinic.

Answer Options

2 : A nurse is caring for a client who has Stage IV lung cancer and was prescribed opioid medications for pain management. The client is unable to engage in most physical activity. Which of the following manifestations should the nurse anticipate?

3 : A nurse is caring for a client who had prostate surgery and is experiencing erectile dysfunction. Which of the following treatment options should the nurse understand can be utilized for this client? (Select all that apply.)

4 : The nurse is caring for a client who has prostate cancer. Which of the following manifestations does the nurse attribute to advancing disease process?

5 : A nurse is assisting with the care of a client who is receiving chemotherapy for breast cancer. Which of the following actions should the nurse understand should occur during administration of oral chemotherapy?

7 : A nurse is reinforcing teaching given to a client regarding the difference between brain death and clinical death. Which client statement indicates accurate understanding?

8 : A nurse is providing care to a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

9 : A nurse is reinforcing teaching to a client who has cancer about angiography. Which of the following statements should the nurse include in the teaching?

10 : A nurse is providing care to a client who states, "l have a DNI status." Which of the following interventions should the nurse be prepared to administer to the client? Select all that apply.

1 :
A nurse is caring for a client at an outpatient clinic.

2 :
A nurse is caring for a client who has Stage IV lung cancer and was prescribed opioid medications for pain management. The client is unable to engage in most physical activity. Which of the following manifestations should the nurse anticipate?

3 :
A nurse is caring for a client who had prostate surgery and is experiencing erectile dysfunction. Which of the following treatment options should the nurse understand can be utilized for this client? (Select all that apply.)

4 :
The nurse is caring for a client who has prostate cancer. Which of the following manifestations does the nurse attribute to advancing disease process?

5 :
A nurse is assisting with the care of a client who is receiving chemotherapy for breast cancer. Which of the following actions should the nurse understand should occur during administration of oral chemotherapy?

7 :
A nurse is reinforcing teaching given to a client regarding the difference between brain death and clinical death. Which client statement indicates accurate understanding?

8 :
A nurse is providing care to a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

9 :
A nurse is reinforcing teaching to a client who has cancer about angiography. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is providing care to a client who states, "l have a DNI status." Which of the following interventions should the nurse be prepared to administer to the client? Select all that apply.