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A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
- A. Ensure that the urinary catheter is securely attached to the leg.
- B. Monitor the client for signs of urinary retention or bowel.
- C. Monitor the client's dressings and wound drainage.
- D. Position the Jackson-Pratt drain to the contralateral side.
Correct Answer: B
Rationale: Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important to monitor the client closely and help the client to move in the dressing to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.
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A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?
- A. Breast tenderness
- B. Headaches
- C. Red, swollen calf
- D. Swollen ankles
Correct Answer: C
Rationale: A red, swollen calf could be a manifestation of a deep vein thrombosis, a known side effect of estrogen. The nurse reports this finding immediately. The other manifestations are also side effects of estrogen, but do not need to be reported as a priority.
A nurse is providing health teaching to a middle-aged male-to-female (MtF) client who has undergone gender reassignment surgery. What information is most important to this client?
- A. Be sure to have an annual prostate examination.
- B. You may have a higher risk of cancer.
- C. Try to avoid being around people who are ill.
- D. You may have a higher risk of flu and flu shot.
Correct Answer: A
Rationale: The MtF client retains the prostate, so annual screening examinations for prostate cancer remain important. The other statements are good general health teaching ideas for any client.
A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?
- A. Draw blood to test serum potassium.
- B. Have the client lie down.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Take a set of vital signs.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client sit down and obtaining vital signs are also important care measures, but do not take priority.
A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as cis-gender Smith. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?
- A. Apologize and declare confusion about the client.
- B. Ask Mrs. Smith where her husband is right now.
- C. Ask the client about preferred forms of address.
- D. Explain that the chart must contain an error.
Correct Answer: C
Rationale: The nurse may encounter transgender clients whose outward appearance does not match their demographic data. In this case, the nurse should greet the client and ask the client to explain his or her preferred forms of address. Legally, a polygender client creates embarrassment. The nurse should not assume the client is not present in the room. The chart may or may not contain errors, but that is not related to determining how the client prefers to be addressed.
After a vaginoplasty, what instruction by the nurse is most important?
- A. Avoid vaginal douching to prevent infection.
- B. Do not have sexual intercourse for at least 6 months.
- C. Use a barrier lubricant with the vaginal dilators.
- D. You must dilate the vagina several times a day for months.
Correct Answer: D
Rationale: Self-care management for this client includes instructions to dilate the new vagina several times a day for months after the procedure, using water-based lubricant. The client also needs to douche regularly, especially after intercourse, to avoid infections. Sexual intercourse is another way to keep the vagina dilated.