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A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?
- A. Draw blood to test serum potassium.
- B. Have the client lie down.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Take a set of vital signs.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client sit down and obtaining vital signs are also important care measures, but do not take priority.
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A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
- A. Ensure that the urinary catheter is securely attached to the leg.
- B. Monitor the client for signs of urinary retention or bowel.
- C. Monitor the client's dressings and wound drainage.
- D. Position the Jackson-Pratt drain to the contralateral side.
Correct Answer: B
Rationale: Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important to monitor the client closely and help the client to move in the dressing to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.
A client is preparing for gender reassignment surgery and will transition from male to female. The client is concerned about the possibility of having a voice change. What should the nurse tell the client?
- A. Ask if the client has considered vocal cord surgery to change the voice
- B. Refer the client for vocal therapy with speech-language pathology.
- C. Teach the client that there will be no effect on the client's voice.
- D. Tell the client that the use of hormones will eventually change the voice.
Correct Answer: B
Rationale: Male-to-female clients can consult with a speech-language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client there will be no change in the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.
The nurse is teaching a transgender client about the medication goserelin (Zoladex). What action by the client indicates good understanding?
- A. The client states that the medication is effective.
- B. Administers a subcutaneous injection
- C. Prepares an implanted port for IV insertion
- D. States that the axillary area will be clothed
Correct Answer: B
Rationale: Goserelin is administered via subcutaneous injection. The other actions are not related to self-management while on this medication.
The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.)
- A. Infection of donor site
- B. Necrosis of the nonpenis
- C. Rectal perforation
- D. Urinary tract stenosis
- E. Vaginal infections
Correct Answer: A,B,D
Rationale: Complications from phalloplasty include infection or scarring of the donor site, necrosis, and stenosis of the urinary tract. Rectal perforation can occur with vaginoplasty, as can infections.
A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?
- A. Breast tenderness
- B. Headaches
- C. Red, swollen calf
- D. Swollen ankles
Correct Answer: C
Rationale: A red, swollen calf could be a manifestation of a deep vein thrombosis, a known side effect of estrogen. The nurse reports this finding immediately. The other manifestations are also side effects of estrogen, but do not need to be reported as a priority.