Nokea
Before taking the client to the room where the pelvic examination will be performed, which nursing action is most appropriate?
- A. Ask the client to sign a consent form.
- B. Give the client a gown to wear.
- C. Offer the client a mild analgesic.
- D. Help the client instill a vaginal lubricant.
Correct Answer: B
Rationale: Providing a gown ensures the client's privacy and comfort during the pelvic examination, which is a priority before the procedure.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP?
- A. Increase the drip rate on the Murphy drip irrigation set.
- B. Check the suprapubic catheter insertion site for infection.
- C. Encourage the two (2)-hour postoperative client to turn and cough.
- D. Document the amount of red drainage in the catheter.
Correct Answer: C
Rationale: Encouraging turning and coughing is within UAP scope to prevent respiratory complications. Adjusting irrigation, checking for infection, and documenting drainage require nursing judgment.
The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group?
- A. The clients should find out about their family history of breast cancer.
- B. Men at this age can get breast cancer also and should be screened.
- C. Monthly breast self-examination is the key to early detection.
- D. The older a woman gets, the greater the chance of developing breast cancer.
Correct Answer: D
Rationale: Age is the most significant risk factor for breast cancer, with risk increasing as women age, especially in seniors. Family history is important but less universal, male breast cancer is rare, and BSE is secondary to awareness and screening.
The male client complains of mucus-like drainage from the rectum accompanied by rectal pain and diarrhea. Which interview question should the nurse ask the client?
- A. Do you have difficulty trying to urinate?'
- B. Have you had rectal sexual intercourse?'
- C. Do you eat a high-fiber diet and drink lots of fluids?'
- D. Does the diarrhea alternate with constipation?'
Correct Answer: B
Rationale: Rectal intercourse is a risk for proctitis or STDs causing mucus, pain, and diarrhea. Urination, diet, and diarrhea patterns are less specific.
The nurse is assessing a male client for symptoms of gonorrhea. Which data support the diagnosis?
- A. Presence of a chancre sore on the penis.
- B. No symptoms.
- C. A CD4 count of less than 200.
- D. Pain in the testes and scrotal edema.
Correct Answer: B
Rationale: Gonorrhea in males can be asymptomatic, especially early. Chancre sores indicate syphilis, low CD4 is HIV-related, and testicular pain/edema suggest epididymitis, not gonorrhea.
Which nursing order is most appropriate to add to the client's initial postoperative care plan?
- A. Connect the cystostomy tube to a leg bag for drainage.
- B. Secure the cystostomy tube to the client's thigh.
- C. Ensure that the cystostomy tube is unclamped at all times.
- D. Clamp the indwelling catheter when the cystostomy tube is irrigated.
Correct Answer: C
Rationale: Keeping the cystostomy tube unclamped ensures continuous drainage, preventing complications like infection or pressure buildup.