Nokea
Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?
- A. Elevating the knee gatch on the bed
- B. Assisting with range-of-motion leg exercises
- C. Removal of antiembolism stockings twice daily
- D. Checking placement of pneumatic compression boots
Correct Answer: A
Rationale: The correct answer is A. Elevating the knee gatch on the bed should be avoided in the care of a client who has undergone a vaginal hysterectomy. This action can inhibit venous return, increasing the risk of deep vein thrombosis or thrombophlebitis. Choices B, C, and D are appropriate nursing interventions for postoperative care to prevent complications and promote circulation.
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A healthcare professional is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the healthcare professional to notify the primary health care provider immediately?
- A. Irregular menses.
- B. Edema in the lower extremities.
- C. Ongoing breast tenderness.
- D. Red, warm, swollen calf.
Correct Answer: D
Rationale: The correct answer is D. A red, warm, swollen calf may indicate a deep vein thrombosis, which is a medical emergency. This finding requires immediate notification of the primary health care provider to prevent potential complications such as pulmonary embolism. Choices A, B, and C are not indicative of life-threatening conditions and should be monitored but do not require immediate notification like a suspected deep vein thrombosis.
When working with clients experiencing alopecia, what is the best method for a nurse to help them manage the psychosocial impact of this issue?
- A. Assisting the client in pre-planning for this event.
- B. Reassuring the client that alopecia is temporary.
- C. Teaching the client ways to protect the scalp.
- D. Telling the client that there are worse side effects.
Correct Answer: A
Rationale: Assisting the client in pre-planning for alopecia is the best method to help them manage the psychosocial impact of the issue. By helping clients anticipate and prepare for the challenges associated with alopecia, they can cope better with the psychological impact. Reassuring the client that alopecia is temporary (choice B) may provide false hope as some types of alopecia are permanent. Teaching ways to protect the scalp (choice C) is important but not the most effective method for managing the psychosocial impact. Telling the client that there are worse side effects (choice D) is dismissive of the client's feelings and not helpful in addressing the psychosocial impact of alopecia.
Which of the following terms is another name for Billroth I?
- A. Gastroduodenostomy
- B. Gastrojejunostomy
- C. Gastroileostomy
- D. Gastrostomy
Correct Answer: A
Rationale: The correct answer is Gastroduodenostomy. Billroth I procedure involves the removal of a part of the stomach (usually the distal portion) and anastomosis of the remaining stomach to the duodenum. This procedure is known as Gastroduodenostomy. Choices B, C, and D are incorrect as they refer to different surgical procedures involving connections with the jejunum, ileum, and creating an opening in the stomach, respectively, not the specific procedure described as Billroth I.
The client is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
- A. I change my pouch every week.
- B. I change the appliance in the morning.
- C. I empty the urinary collection bag when it is two-thirds full.
- D. When I'm in the shower, I direct the flow of water away from my stoma.
Correct Answer: D
Rationale: The correct answer is D because directing water away from the stoma while showering is incorrect. The stoma can and should be cleaned with water. Choices A, B, and C demonstrate proper stoma care practices, such as changing the pouch regularly, changing the appliance in the morning, and emptying the collection bag when it is two-thirds full, which are all appropriate actions for caring for a urinary stoma.
All of the following are warning signs of cancer except:
- A. Patient palpates a bump on the side of the breast
- B. Bruises are found on the body that the client cannot explain
- C. Patient often complains of impaired digestion
- D. Patient has blood-tinged sputum
Correct Answer: D
Rationale: The correct answer is D. Blood-tinged sputum is not a typical warning sign of cancer but rather a symptom that can indicate other serious conditions like respiratory issues or infections. Choices A, B, and C are common warning signs of cancer: palpable lumps or bumps, unexplained bruises, and persistent digestive issues are often associated with cancer and should be evaluated by a healthcare professional for further assessment and diagnosis.