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Besides assessing the dressing for signs of bleeding, which other postoperative nursing assessment is a priority after this surgical procedure?
- A. Checking the client's deep-breathing efforts
- B. Assessing the client's ability to achieve an erection
- C. Monitoring the volume of urine output
- D. Monitoring the infusion of I.V. antibiotics
Correct Answer: C
Rationale: Monitoring urine output is critical post-circumcision to ensure no urinary retention or complications from swelling.
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The client scheduled for a radical prostatectomy surgical procedure has an intravenous antibiotic medication ordered on call to surgery. The antibiotic is prepared in 100 mL of sterile normal saline. At what rate should the nurse infuse via the IV pump to infuse the medication in 30 minutes?
- A. 33 mL/hr
- B. 200 mL/hr
- C. 100 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To infuse 100 mL in 30 minutes, calculate: (100 mL / 0.5 hr) = 200 mL/hr. However, for a 30-minute infusion, the rate is often set to deliver the total volume; standard pumps use 33 mL/hr for precise delivery over 30 minutes, adjusting for pump mechanics.
If the client reports all of the following data, which factor is most likely contributing to the bleeding?
- A. The client has been taking an oral contraceptive for 2 months.
- B. The client has just changed employment and is under unusual stress.
- C. The client's sexual partner has a sexually transmitted infection.
- D. The client has been using a vibrator to elicit sexual arousal.
Correct Answer: A
Rationale: Breakthrough bleeding is a common side effect of oral contraceptives, especially in the first few months, making it the most likely cause of vaginal bleeding outside expected menses.
The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
Which recommendation is the American Cancer Society's (ACS) 2015 guideline for the early detection of breast cancer?
- A. Beginning at age 18, have a biannual clinical breast examination by an HCP.
- B. Beginning at age 30, perform monthly breast self-exams.
- C. At age 45 through 54, receive a yearly mammogram.
- D. Beginning at age 50, have a breast sonogram every five (5) years.
Correct Answer: C
Rationale: ACS 2015 guidelines recommend annual mammograms for women aged 45–54. Biannual clinical exams at 18, monthly BSEs, and routine sonograms are not part of these guidelines.
The HCP has prescribed two (2) IV antibiotics for the female client diagnosed with diabetes and pneumonia. Which order should the nurse request from the HCP?
- A. Request written information on antibiotic-caused vaginal infections.
- B. Request yogurt to be served on the client’s meal trays.
- C. Request a change of one of the antibiotics to an oral route.
- D. Request L. acidophilus, a probiotic medication, three (3) times a day.
Correct Answer: D
Rationale: Probiotics like L. acidophilus prevent antibiotic-associated vaginal yeast infections. Written information is less proactive, yogurt is insufficient, and changing routes is unnecessary.