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A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding?
- A. Client who has a temperature of 99.6°F and a pulse of the last 2 hours
- B. Client with a temperature of 99.0°F and blood pressure of 115/73 mm Hg
- C. Client who has pain of 6 on a scale of 0 to 10
- D. Client with a urinary catheter output of 150 mL in the last 3 hours
Correct Answer: A
Rationale: None of vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.
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A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.)
- A. Reduce the pain by low-level heat.
- B. Discuss in detail the side effects of laparoscopic surgery.
- C. Reduce anxiety by relaxation techniques and education.
- D. Suggest resources such as the Endometriosis Association.
- E. Encourage the client to avoid all physical activity.
Correct Answer: A,C,D
Rationale: With endometriosis, pain is the predominant symptom, with anxiety occurring because of the diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat, relaxation techniques, and education about the pathophysiology and possible treatment of endometriosis. The nurse could suggest resources like the Endometriosis Association. Discussing surgical side effects in detail is not appropriate without assessing the client's readiness, and avoiding all physical activity is not recommended as it may not help manage symptoms.
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.
The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is incorrect?
- A. Listen attentively to the client's concerns.
- B. Let the client alone for a long period of reflection time.
- C. Ask friends and relatives to limit their visits.
- D. Tell the client that an emotional response is unacceptable.
- E. Create an atmosphere of acceptance and discussion.
Correct Answer: D
Rationale: Discussion of a client's concerns about the presence of cancer and the potential for recurrence will provide emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives. An emotional response should be accepted.
The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.)
- A. Constipation for 3 days
- B. Severe diarrhea
- C. Abdominal pain
- D. Visible blood in the urine
- E. Heavy vaginal bleeding
Correct Answer: C,D,E
Rationale: Health teaching for a client having brachytherapy should emphasize reporting abdominal pain, visible blood in the urine, and heavy vaginal bleeding. Severe diarrhea, urethral burning, extreme fatigue, and a fever over 100°F should also be reported. Constipation for 3 days is not typically a critical symptom to report immediately in this context.
A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate?
- A. You are too old to receive an HPV vaccine.
- B. Either Gardasil or Cervarix can provide protection.
- C. You will need to have three injections over a span of 1 year.
- D. The most common side effect of the vaccine is itching at the injection site.
Correct Answer: B
Rationale: Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is recommended that younger women, 19-26 years, should receive an HPV vaccine. The series consists of three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very common, but this does not include itching.