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 preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
- A. Avoid foods high in fat.
- B. Avoid foods high in carbohydrates.
- C. Eat a high-protein, low-fat diet.
- D. Increase intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in fat. Biliary colic is caused by gallstones, and high-fat foods can trigger gallbladder contractions leading to pain. Therefore, advising the client to avoid foods high in fat can help prevent biliary colic episodes. Choice B is incorrect as carbohydrates do not directly affect biliary colic. Choice C is incorrect because while a high-protein, low-fat diet may be beneficial for some conditions, it is not specifically recommended for biliary colic. Choice D is incorrect as increasing intake of high-fat foods can worsen symptoms.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
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.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
- A. Clamp the chest tube during transport.
- B. Keep the drainage system below the level of the client's chest at all times.
- C. Remove the chest tube for transport.
- D. Allow the client to carry the drainage system.
Correct Answer: B
Rationale: The correct answer is B: Keep the drainage system below the level of the client's chest at all times. This is crucial because maintaining the drainage system below the chest level prevents backflow of air or fluid into the client's chest cavity, which can lead to complications like tension pneumothorax or fluid re-entering the pleural space. Clamping the chest tube can cause a build-up of pressure and should only be done in emergency situations. Removing the chest tube is unsafe and can lead to respiratory distress. Allowing the client to carry the drainage system can risk dislodging the tube or causing tension on the connections. Therefore, the best option is to keep the drainage system below the chest level to ensure proper drainage and prevent complications.
A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.