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A client has a recurrent Bartholin cyst. What is the nurse's priority action?
- A. Apply an ice pack to the area.
- B. Administer a prophylactic antibiotic.
- C. Support a fluid transfer to the liver analysis.
- D. Suggest moist heat such as a sitz bath.
Correct Answer: C
Rationale: A major cause of an obstructed duct forming a cyst is infection. The laboratory specimen is a priority since a culture is needed in order to prescribe sensitive antibiotics. Comfort measures can then be used, such as ice packs and moist heat.
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The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement by the client indicates a lack of understanding?
- A. I need to change the tampon every 3 hours during the day.
- B. At night, I should use a feminine pad rather than a tampon.
- C. If I don't use tampons, I should not get TSS.
- D. I should wash my hands before inserting the tampon.
Correct Answer: A
Rationale: Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus. All of the other responses are correct: using feminine pads only, not using tampons at all, and washing hands before tampon insertion are all strategies to prevent TSS.
A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important?
- A. Administer IV fluids to maintain fluid and electrolyte balance.
- B. Remove the tampon as the source of infection.
- C. Collect a blood specimen for culture and sensitivity.
- D. Transfuse the client to manage low blood count.
Correct Answer: B
Rationale: The source of infection should be removed first. All of the other answers are possible interventions depending on the client's symptoms and vital signs, but removing the tampon is the priority.
A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse?
- A. You are only radioactive when the radioactive implant is in place.
- B. To be totally safe, it is a good idea to sleep in a separate room.
- C. It is best to stay a safe distance from friends or family between treatments.
- D. You should use a separate bathroom from the rest of the family.
Correct Answer: A
Rationale: In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments.
A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess heart, toileting, and bowel sounds.
- B. Check the hemoglobin and hematocrit levels.
- C. Evaluate the dressing for drainage.
- D. Monitor the client for a urinary output.
Correct Answer: D
Rationale: The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.
A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best?
- A. Suggest increasing vitamins and supplements daily.
- B. Discuss the value of a balanced diet and exercise.
- C. Reinforce that weight gain may be inevitable.
- D. Teach that estrogen cream inserted vaginally may help.
Correct Answer: D
Rationale: Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy. Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.