Nokea
The licensed practical nurse (LPN) realizes that the nursing assistant requires further instruction when observing which activities after the client's hysterectomy? Select all that apply.
- A. Frequently offering the client a variety of oral fluids
- B. Helping the client ambulate in the hall
- C. Raising the knee gatch on the hospital bed
- D. Reporting to the physician that the client's dressing is loose
- E. Changing the client's perineal pad without using gloves
Correct Answer: C,E
Rationale: Raising the knee gatch can impair circulation, and changing pads without gloves risks infection. Other actions are appropriate post-hysterectomy care.
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Which statement is most accurate when discussing hair loss with the client?
- A. The hair loss is permanent, but attractive wigs are available.
- B. The hair loss is permanent, but hair transplantation is a possible solution.
- C. The hair loss is temporary; hair may grow back in several years.
- D. The hair loss is temporary; hair will regrow after chemotherapy is finished.
Correct Answer: D
Rationale: Hair loss from chemotherapy is typically temporary, with regrowth occurring after treatment ends, usually within months.
The client is diagnosed with left mastitis. Which assessment findings should the nurse observe?
- A. Dimpling of the left breast when the client raises the arm.
- B. A round lump in the left breast that is tender during menses.
- C. A dull pain in the left breast and tough, doughy feeling skin.
- D. Bloody discharge from the nipple and a hard palpable mass.
Correct Answer: C
Rationale: Mastitis causes dull pain and tough, doughy skin due to inflammation. Dimpling suggests cancer, cyclical lumps are fibrocystic, and bloody discharge/mass indicates malignancy.
If the client tells the nurse that she would prefer to postpone the mastectomy until the biopsy has been more thoroughly examined, which is the most appropriate initial nursing action?
- A. Explain that most biopsies are accurate.
- B. Advocate for her choice of treatment.
- C. Discourage her from opposing the physician.
- D. Recommend that she seek a second opinion.
Correct Answer: B
Rationale: Advocating for the client's preferences supports patient autonomy and ensures her concerns are addressed, aligning with patient-centered care principles.
The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make?
- A. The hospital social worker.
- B. CanSurmount.
- C. Reach to Recovery.
- D. I CanCope.
Correct Answer: C
Rationale: Reach to Recovery provides peer support from breast cancer survivors, addressing emotional and practical needs post-diagnosis. Social workers, CanSurmount, and I CanCope are valuable but less specific to breast cancer support.
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.