Nokea
A nurse is reading a journal article about the care of a woman with pelvic organ prolapse. Would expect to find information on which disorder. Select all that apply.
- A. Rectal incontinence
- B. Rectocele
- C. Urinary incontinence
- D. Cystocele
- E. Enterocele
- G. B,C,D,E
Correct Answer: Pelvic organ prolapse involves disorders like rectocele (rectum bulging into vagina), urinary incontinence (bladder control loss), cystocele (bladder bulging into vagina), and enterocele (small intestine bulging into vagina). Rectal incontinence is not directly related.
Rationale:
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A nurse is caring for a client who is one day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?
- A. Refusing to look at the dressing or surgical incision
- B. Asking questions about the information on her postoperative care pamphlet
- C. Performing arm exercises once or twice a day
- D. Asking for pain medication every 3 hours
- G. A
Correct Answer: Refusing to look at the incision may indicate denial or body image issues. Asking questions, exercising, and requesting pain relief suggest positive coping.
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:
While obtaining a health history from a male adolescent during a good check-up, the nurse assesses his sexual behavior and risk for sexually transmitted infections. Based on the information, the nurse plans to teach the adolescent about using a condom. What statement would the nurse include in the teaching plan?
- A. Store your condoms in your wallet so they are ready for use.
- B. Use petroleum jelly with a latex condom for extra lubrication.
- C. Put the condom on before engaging in any genital contact.
- D. You can reuse a condom if it's within 3 hours.
- G. C
Correct Answer: Applying a condom before genital contact prevents STI and pregnancy transmission. Wallets damage condoms, petroleum jelly weakens latex, and reusing condoms increases infection risk.
Rationale:
A nurse is preparing a client for radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?
- A. Diarrhea
- B. Anorexia
- C. Fatigue
- D. Alopecia
- G. C
Correct Answer: Fatigue is a common side effect of radiation due to damage to healthy cells. Diarrhea and anorexia are more associated with gastrointestinal or systemic treatments, and alopecia is typical with chemotherapy.
Rationale:
A nurse is preparing to administer Ringer's lactate by continuous IV infusion at 120 mL/hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 20 gtt/min
- B. 15 gtt/min
- C. 25 gtt/min
- D. 30 gtt/min
- G. A
Correct Answer: Using the formula gtt/min = (mL/hr x drop factor) / 60, calculate: (120 x 10) / 60 = 20 gtt/min.
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