Nokea
List in order of priority the immediate postoperative mastectomy nursing actions.
- A. Elevate the affected arm with pillows above the level of the right atrium to promote comfort and lymphatic channel return.
- B. Assess vital signs, being careful not to use the affected arm for blood pressure measurement, and monitor parenteral fluids.
- C. Monitor for hemorrhage by assessing drainage from dressing and drainage tubes.
- D. Teach and reinforce the use of relaxation techniques to help reduce anxiety and provide distraction.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and monitoring parenteral fluids are essential postoperative nursing actions to detect any signs of complications such as hemorrhage or fluid imbalance. This prioritizes the patient's physiological stability and safety. Elevating the affected arm (A) is important for comfort but not as immediate as monitoring vital signs. Monitoring for hemorrhage (C) is crucial but comes after ensuring the patient's physiological stability. Teaching relaxation techniques (D) is important for holistic care but is not as immediate as monitoring vital signs and fluid balance.
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A client has an HSV-2 infection. The nurse recognizes that which of the following should be included in teaching the patient?
- A. The virus causes cold sores of the lips.
- B. Treatment is focused on relieving symptoms.
- C. The virus is cured with antibiotics.
- D. The virus is transmitted only when visible lesions are present.
Correct Answer: B
Rationale: The correct answer is B because HSV-2 is a sexually transmitted infection that causes genital herpes. Treatment focuses on managing symptoms like antiviral medications, not curing the virus. Explanation of other choices: A is incorrect because HSV-2 causes genital sores, not cold sores on the lips. C is incorrect because antibiotics do not cure viral infections. D is incorrect because HSV-2 can be transmitted even when there are no visible lesions through asymptomatic shedding.
What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis?
- A. Edema
- B. Immature red blood cells
- C. Enlargement of the heart
- D. Ascites
Correct Answer: B
Rationale: The correct answer is B: Immature red blood cells. Erythroblastosis fetalis is a condition where maternal antibodies attack fetal red blood cells, leading to hemolysis and the release of immature red blood cells (erythroblasts) into the circulation. This can result in anemia and jaundice in the infant. Edema (choice A) is not a typical clinical finding in erythroblastosis fetalis. Enlargement of the heart (choice C) is more commonly associated with conditions like congestive heart failure. Ascites (choice D) is the accumulation of fluid in the abdominal cavity and is not a characteristic finding in erythroblastosis fetalis.
A client with mild preeclampsia who has been advised to be on bed rest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client?
- A. "Bed rest will help you to conserve energy for your labor."'
- B. "Bed rest will help to relieve your nausea and anorexia."'
- C. "Reclining will increase the amount of oxygen that your baby gets."'
- D. "The position change will prevent the placenta from separating."'
Correct Answer: C
Rationale: The correct answer is C because reclining will help improve blood flow to the placenta, increasing oxygen delivery to the baby. This is crucial in preeclampsia to prevent complications such as fetal growth restriction.
A: Incorrect. Bed rest in preeclampsia is not primarily for energy conservation but to reduce blood pressure and prevent further complications.
B: Incorrect. Bed rest does not directly address nausea and anorexia associated with preeclampsia; it focuses on maternal and fetal well-being.
D: Incorrect. Position change does not directly prevent placental separation in preeclampsia; it is more related to maintaining adequate blood flow to the placenta.
A woman is noted to have multiple soft warts on her perineum and rectal areas. The nurse suspects that this client has which type of infection?
- A. HIV
- B. HPV
- C. Syphilis
- D. Herpes simplex virus
Correct Answer: B
Rationale: The correct answer is B: HPV. Human papillomavirus (HPV) causes soft warts in the perineum and rectal areas. HPV is a common sexually transmitted infection known to cause genital warts. The other choices are incorrect because HIV does not typically present with warts, syphilis manifests with painless sores rather than soft warts, and herpes simplex virus causes painful blisters rather than soft warts in the specified areas.
A woman has been diagnosed with single intraductal papilloma and has nipple discharge. Which diagnostic tests will most likely be required?
- A. MRI
- B. Mammogram
- C. Core needle biopsy
- D. Ductogram
Correct Answer: D
Rationale: The correct answer is D: Ductogram. In a patient with single intraductal papilloma and nipple discharge, a ductogram is the most appropriate diagnostic test to visualize the ductal system for any abnormalities. A ductogram involves injecting contrast dye into the affected duct to identify any blockages or abnormalities. This test helps in determining the extent of the papilloma and planning appropriate treatment.
Rationale for incorrect choices:
A: MRI - While MRI can provide detailed images, it is not the primary test for evaluating intraductal papilloma and nipple discharge.
B: Mammogram - Mammogram is used for breast imaging but may not provide detailed visualization of the ductal system.
C: Core needle biopsy - While a biopsy may be needed to confirm the papilloma, it does not directly assess the ductal system for other abnormalities.