Nokea
A nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel?
- A. Obtaining a midstream urine specimen
- B. Interpreting a bladder scan result
- C. Inserting a straight catheter
- D. Irrigating a catheter
Correct Answer: A
Rationale: The correct answer is A: Obtaining a midstream urine specimen. This task is within the scope of practice for nursing assistive personnel as it involves collecting a specimen, which is a routine and non-invasive procedure. Nursing assistive personnel are trained to perform basic tasks like specimen collection. Choices B, C, and D involve more complex skills and procedures that require specialized training and knowledge, which are typically performed by licensed nurses. Interpreting bladder scan results (B), inserting a straight catheter (C), and irrigating a catheter (D) all require a higher level of expertise and assessment that nursing assistive personnel are not qualified to do.
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A clinic nurse is providing preprocedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.
- A. Abstaining from sexual intercourse for at least 14 days postprocedure
- B. Wearing a scrotal support garment
- C. Using sitz baths
- D. Applying a heating pad intermittently E) Staying on bed rest for 48 to 72 hours postprocedure
Correct Answer: A
Rationale: The correct answer is A: Abstaining from sexual intercourse for at least 14 days postprocedure. This is important to allow the surgical site to heal properly and reduce the risk of complications. Choice B, wearing a scrotal support garment, can provide comfort but does not directly enhance healing. Choice C, using sitz baths, may help with discomfort but may not specifically promote healing. Choice D, applying a heating pad intermittently, could potentially increase the risk of infection. Choice E, staying on bed rest for 48 to 72 hours postprocedure, is unnecessary and could lead to complications such as blood clots.
Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?
- A. Ovarian cyst 2 years ago
- B. Recurrent pelvic infections
- C. Use of oral contraceptives for 5 years
- D. Heavy menstrual flow of 4 days’ duration
Correct Answer: B
Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is N R I G B.C M U S N T O based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications.
Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.
A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what?
- A. Urinary tract infection
- B. Chronic pain
- C. Permanent vascular damage
- D. Future erectile dysfunction
Correct Answer: C
Rationale: The correct answer is C: Permanent vascular damage. Priapism is a prolonged erection that can lead to ischemia and damage to the penile tissue due to impaired blood flow, potentially resulting in permanent vascular damage. Urinary tract infection (A) is unrelated to priapism. Chronic pain (B) may occur but is not the primary concern. Future erectile dysfunction (D) can result from priapism but is not as immediate or severe as permanent vascular damage. Therefore, C is the most critical consequence to address in priapism.
A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
- A. Metastasis
- B. Risk for stroke
- C. Emotional and personality changes
- D. Pathologic bone fractures
Correct Answer: C
Rationale: The correct answer is C: Emotional and personality changes. In Huntington disease, neurodegeneration affects the brain, leading to changes in behavior, emotions, and personality. These changes are characteristic of the disease progression. Metastasis (A) refers to the spread of cancer, which is not associated with Huntington disease. Risk for stroke (B) is not a typical manifestation of Huntington disease. Pathologic bone fractures (D) are not directly related to the primary symptoms of Huntington disease. Thus, addressing emotional and personality changes is crucial in providing anticipatory guidance for individuals with Huntington disease.