Nokea
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.
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A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider?
- A. Headache
- B. Nausea
- C. Musculoskeletal pain
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can cause musculoskeletal pain as a common adverse effect. This is important to report because severe pain may indicate a more serious condition like osteoporosis or fractures. Headache, nausea, and fatigue are common side effects of anastrozole but usually not considered serious enough to report immediately. Summarily, while all options can occur with anastrozole, musculoskeletal pain warrants prompt reporting due to potential implications on bone health.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Inspect the mouth for signs of inhalation injuries
- B. Administer pain medication
- C. Place the client on oxygen therapy
- D. Start an intravenous line
Correct Answer: A
Rationale: The correct answer is A: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening and must be assessed immediately in burn patients. Burns to the face and chest increase the risk of inhalation injuries due to the proximity to the airway. Administering pain medication, placing the client on oxygen therapy, and starting an IV line are important interventions but inspecting the mouth for signs of inhalation injuries takes precedence in this situation to ensure the client's airway is not compromised.
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Tinel's sign
- B. Phalen's test
- C. Rinne's test
- D. Romberg test
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (C) is used to assess for hearing loss. Romberg test (D) is used to assess for balance and proprioception issues. Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.