The public health nurse is teaching young adolescents in a sexual health class the proper use of a condom. Which statements made by the students indicate teaching was successful? Select all that apply.
- A. Baby oil is an acceptable lubricant.
- B. Ensure a tight fit of the condom.
- C. Only use latex condoms.
- D. Place the condom on an erect penis.
- E. Store the condoms in a cool dry place.
- G. C,D,E
Correct Answer: Latex condoms are effective against STIs and pregnancy, unlike natural skin condoms. Condoms should be applied on an erect penis to prevent slippage, and stored in a cool, dry place to avoid damage. Baby oil degrades latex, and a tight fit increases breakage risk.
Rationale:
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A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?
- A. Fluid balance
- B. Body image
- C. Urinary elimination
- D. Activity
- G. B
Correct Answer: Body image is a priority due to the psychosocial impact of mastectomy on identity and self-esteem. Fluid balance, urinary elimination, and activity are less immediate concerns.
Rationale:
A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet on the client's right arm. Which action by the nurse would be most appropriate?
- A. Call the surgeon to perform a femoral puncture.
- B. Assist in holding the client's arm still.
- C. Tell the technician to obtain the blood sample from the client's left arm.
- D. Suggest a finger stick be done on one of the client's left fingers.
- G. C
Correct Answer: Using the left arm avoids risks like lymphedema in the surgical arm. Femoral puncture is invasive, assisting with the right arm is harmful, and finger sticks are inadequate for CBC.
Rationale:
Which finding would the nurse expect in a client with bacterial vaginosis?
- A. Vaginal pH of 3
- B. Cervical bleeding on contact
- C. Fishy odor of discharge
- D. Yellowish-green discharge
- G. C
Correct Answer: Bacterial vaginosis causes a fishy-smelling, thin, gray-white discharge due to anaerobic bacteria. Vaginal pH rises above 4.5, cervical bleeding suggests other issues, and yellowish-green discharge indicates other infections.
Rationale:
A client is diagnosed with uterine fibroids. When reviewing the client's health history, the nurse would identify which finding is associated with the client's condition.
- A. Upper back pain
- B. Chronic pelvic pain
- C. Amenorrhea
- D. Diarrhea
- G. B
Correct Answer: Uterine fibroids cause chronic pelvic pain due to pressure on nerves and organs. Back pain, amenorrhea, and diarrhea are not typical symptoms.
Rationale:
A nurse is reinforcing teaching about self-care with a client who has pelvic inflammatory disease. The client does not speak English. Which of the following actions by the nurse is appropriate?
- A. Ask the client's English-speaking family member to translate.
- B. Use a translation dictionary to reinforce the teaching.
- C. Seek assistance from a facility-approved interpreter.
- D. Ask an assistive personnel (AP) who speaks the client's language to serve as an interpreter.
- G. C
Correct Answer: A facility-approved interpreter ensures accurate and confidential communication. Family members may lack medical knowledge, dictionaries are inefficient, and APs may not be qualified or authorized to interpret.
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