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The client is being discharged after a left wedge resection. Which discharge instructions should the nurse include? Select all that apply.
- A. Notify the HCP of a temperature of 100°F.
- B. Carry large purses and bundles with the right hand.
- C. Do not go to church or anywhere with crowds.
- D. Try to keep the arm as still as possible until seen by the HCP.
- E. Have a mammogram of the right and left breasts yearly.
Correct Answer: A,B,E
Rationale: Notify HCP for fever (infection risk), use right hand for heavy items (protect left arm), and annual mammograms (continued screening) are appropriate. Avoiding crowds is unnecessary, and immobilizing the arm is not advised; gentle movement aids recovery.
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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 nurse writes a problem of 'potential for complications related to ovarian hyperstimulation' for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?
- A. Instruct the client to delay intercourse until menses.
- B. Schedule the client for frequent pelvic sonograms.
- C. Explain the infusion therapy will take 21 days.
- D. Discuss that this may cause an ectopic pregnancy.
Correct Answer: B
Rationale: Frequent pelvic sonograms monitor for ovarian hyperstimulation syndrome (OHSS), a clomiphene risk. Delaying intercourse, infusion therapy, and ectopic pregnancy are unrelated.
Which nursing diagnosis is most appropriate for the nurse to add to the client's care plan at this time?
- A. Risk for ineffective airway clearance
- B. Risk for imbalanced nutrition
- C. Ineffective coping
- D. Impaired verbal communication
Correct Answer: A
Rationale: General anesthesia and abdominal surgery increase the risk of respiratory complications, making ineffective airway clearance a priority diagnosis.
The office manager schedules a mandatory staff meeting for all nursing personnel. As the nurse enters the room, several documents containing the client's name, medical records number, mammogram results, and diagnosis are found unattended on the table. Which nursing actions are appropriate in this situation? Select all that apply.
- A. Notify housekeeping to come and dispose of the papers.
- B. Toss the papers in the trash.
- C. Put the papers into the shredder bin.
- D. Try to determine who left the papers unattended.
- E. State the papers neatly, placing them off to the side.
- F. Notify the office manager of the breach in confidentiality.
Correct Answer: C,F
Rationale: Shredding the papers ensures secure disposal of protected health information (PHI), and notifying the office manager addresses the confidentiality breach, as required by HIPAA regulations.
What intervention should the nurse implement for a client diagnosed with a rectocele?
- A. Limit oral intake to decrease voiding.
- B. Encourage a low-residue diet.
- C. Administer a stool softener daily.
- D. Arrange for the client to take sitz baths.
Correct Answer: C
Rationale: Stool softeners prevent straining during bowel movements, reducing rectocele pressure. Limiting intake is inappropriate, low-residue diets increase constipation risk, and sitz baths are less specific.