Nokea
A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?
- A. Brushing her teeth
- B. Buttoning her blouse
- C. Eating her breakfast
- D. Combing her hair
- G. D
Correct Answer: Combing hair requires lifting the arm above the shoulder, which can be painful and difficult due to impaired lymphatic drainage and nerve damage post-mastectomy. Brushing teeth, buttoning a blouse, and eating are less challenging as they require minimal arm elevation or strength.
Rationale:
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A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients has a contraindication for receiving oral contraceptives.
- A. A 26-year-old client who has migraine headaches at the start of each menstrual cycle
- B. A 28-year-old client who has a history of pelvic inflammatory disease
- C. A 32-year-old client who has benign breast disease
- D. A 38-year-old client who reports smoking one pack of cigarettes every day
- G. D
Correct Answer: Smoking, especially over age 35, increases cardiovascular risks with oral contraceptives, making it a contraindication. Migraines, PID history, and benign breast disease are not absolute contraindications.
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 nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?
- A. If your sexual partner has no symptoms, no medication is needed.
- B. This infection is treated with one dose of azithromycin.
- C. You need to return in 6 months for retesting.
- D. You have to avoid sexual relations for 3 days.
- G. B
Correct Answer: Chlamydia is treated with a single dose of azithromycin. Partners need treatment regardless of symptoms, retesting is only needed in specific cases, and sexual activity should be avoided until treatment is complete, which may take longer than 3 days.
Rationale:
After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:
- A. Sexual experience
- B. Menstrual period
- C. Signs of breast development
- G. B
Correct Answer: Menarche is the first menstrual period, marking the onset of fertility. Sexual experience and breast development are unrelated to this definition.
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: