Nokea
A nurse is caring for a client following a culdoscopy. Which assessment data would the licensed practical nurse report to the registered nurse?
- A. Pain level of 7 on the 0-to-10 pain scale
- B. Skin, cold, pulse, 110 beat/minute, blood pressure, 104/64 mm Hg
- C. Dark drainage noted on surgical pad
- D. Fleshy smell noted to perineal region
Correct Answer: B
Rationale: Culdoscopy is performed to visualize the uterus, broad ligaments, and fallopian tubes. An endoscope is inserted through a small incision made in the posterior vaginal wall. Afterward, the nurse must observe for signs of internal bleeding and shock. A client with cold and clammy skin, a rapid pulse, and low blood pressure indicates shock and the need to consult the registered nurse and even the physician. All of the other symptoms are able to be addressed by the licensed practical nurse. The client is to be medicated. Dark drainage and a fleshy smell to the perineal area are normal for old surgical drainage.
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The nurse is obtaining a health history at the client's annual gynecologic exam. Which of the following statements regarding a Papanicolaou test (Pap test) for cancer screening would delay the exam?
- A. I had sexual intercourse several days ago.
- B. I voided before entering the exam room.
- C. My menstrual period began yesterday.
- D. I use no vaginal sprays or creams.
Correct Answer: C
Rationale: The nurse advises that the Pap test be rescheduled to a time other than during the menstrual period. The other options are acceptable to continue the test procedure.
A nurse is caring for a client who is being evaluated for a lump found on the lateral aspect of the right breast. The client is anxious and asks the nurse if the next step is to have a mastectomy. Which is the nurse's best response?
- A. Yes, breast lumps are abnormal and will need to be removed.
- B. The doctor will need a biopsy first to see if the lump is cancerous.
- C. The doctor will answer your questions when he or she arrives.
- D. Many times, an ultrasound is done to distinguish between a tumor and cyst.
Correct Answer: D
Rationale: Ultrasonography is often used with a mammogram after a breast lump is found to provide additional data on the breast lump. An ultrasound can differentiate if the lump is a fluid-filled cyst or other types of breast lesions. This step may be used before a mastectomy is performed or even a biopsy is completed. The nurse is able to provide factual information on common treatment paths, understanding that it is the physician who prescribes the medical care.
The nurse is caring for a client scheduled for a transrectal ultrasonography. Which instruction is essential in obtaining an accurate test?
- A. Self-administer an enema prior to arrival.
- B. Take a low-dose sedative prior to arrival.
- C. Avoid fluids after midnight.
- D. Empty the bladder prior to the exam.
Correct Answer: A
Rationale: The client will need to have an enema to remove stool from the rectum so that the ultrasound can penetrate through the tissues to visualize structures of the prostate. Typically, a sedative is not needed as the client uses normal relaxation techniques. Urine status is not the focus of the exam requiring that fluids be withheld. For the client's comfort, the nurse may encourage emptying the bladder before the exam.
The nurse is outlining the female internal reproductive structures on a diagram. Where on the diagram would the nurse highlight the typical site of ovum fertilization?
- A. The nurse would highlight the uterus.
- B. The nurse would highlight the cervix.
- C. The nurse would highlight the fallopian tube.
- D. The nurse would highlight the ovaries.
Correct Answer: C
Rationale: The nurse would highlight the fallopian tubes as the site of ovum fertilization. Once fertilized, the fertilized egg moves to the uterus for implantation. The cervix is the lower, narrowed neck portion leading to the center of the uterus. The ovaries release the ovum, which is swept into the fallopian tubes.
A nurse is employed by a fertility clinic. Diagnostic testing is being completed to determine the source of the male not producing viable sperm to enable ovum fertilization. Which male structures does the nurse consider if the problem is narrowed to sperm survivability?
- A. Bartholin glands
- B. Prostate gland
- C. Cowper glands
- D. Vas deferens
Correct Answer: B
Rationale: The accessory structure of the prostate gland contains secretory cells that produce alkaline fluid. The prostatic fluid mixes with sperm. The alkalinity of the prostatic fluid neutralizes the acidic metabolic wastes released by the sperm and counteracts the acid pH within the vagina to ensure mass survival of the sperm. The Cowper glands add lubrication for penetration of the vagina.