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A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
- A. Ask about the client's exposure to any past or present STIs.
- B. Advise clients not to disclose their sexual history.
- C. Focus only on present symptoms of STIs.
- D. Only ask about high-risk behavior.
Correct Answer: A
Rationale: The correct answer is A because asking about the client's exposure to any past or present STIs is crucial for effective counseling. Understanding the client's history helps in assessing risk factors, determining appropriate interventions, and providing tailored education. It also promotes trust and open communication.
Choice B is incorrect as advising clients not to disclose their sexual history hinders the nurse's ability to provide comprehensive care and support. Choice C is incorrect because focusing only on present symptoms may overlook important information needed for proper assessment and management. Choice D is incorrect as only asking about high-risk behavior limits the scope of the assessment and may miss potential risk factors.
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A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
- A. Excessive thrombosis and bleeding
- B. Clotting of the mucous membranes
- C. Increase in platelet count
- D. Excessive red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.
A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
A nurse teaches a client with breast cancer about chemotherapy side effects. What statement indicates understanding?
- A. I'll call my doctor if I notice any unusual menstrual bleeding.
- B. I'll stop chemotherapy if I feel tired.
- C. Hair loss is always permanent.
- D. I don't need any follow-up tests after treatment.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the importance of monitoring for potential side effects like unusual menstrual bleeding, which can be a serious complication of chemotherapy. This statement reflects proactive involvement in self-care and prompt communication with healthcare providers. Choices B, C, and D are incorrect because stopping chemotherapy without medical guidance can be harmful, hair loss may not always be permanent, and follow-up tests are essential for monitoring treatment effectiveness and potential complications.
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Absence of bubbling in the water seal chamber
- D. No drainage in the collection chamber
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
- A. The urethral orifice is assessed by separating the labia minora.
- B. The cervix should be palpated first.
- C. The external genitalia should not be inspected.
- D. The perineum should be assessed after the vaginal examination.
Correct Answer: A
Rationale: The correct answer is A because the urethral orifice is located between the clitoris and the vaginal opening, so separating the labia minora allows for proper visualization and assessment. This step ensures accurate examination of the urethral opening for signs of infection or abnormalities. Palpating the cervix first (B) is incorrect as it should be done after inspecting the external genitalia. Choosing not to inspect the external genitalia (C) is incorrect as it is an essential part of the gynecological examination. Assessing the perineum after the vaginal examination (D) is incorrect as the perineum should be assessed before the vaginal examination to evaluate for any abnormalities or injuries.