Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a gynecology surgery floor. Which intervention cannot be delegated to the UAP?
- A. Empty the indwelling catheter on the three (3)-hour postoperative client.
- B. Assist the client who is two (2) days post-hysterectomy to the bathroom.
- C. Monitor the peri-pad count on a client diagnosed with fibroid tumors.
- D. Encourage the client who is refusing to get out of bed to walk in the hall.
Correct Answer: C
Rationale: Monitoring peri-pad count involves assessing bleeding, requiring nursing judgment. Emptying catheters, assisting to the bathroom, and encouraging ambulation are within UAP scope.
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The client diagnosed with cancer of the prostate tells the nurse, 'I caused this by being promiscuous when I was young and now I have to pay for my sins.' Which statement is the nurse’s most therapeutic response?
- A. Why would you think prostate cancer is caused by sex?'
- B. You feel guilty about some of your actions when you were young?'
- C. Well, there is nothing you can do about that behavior now.'
- D. Have you told the HCP and been checked for an AIDS infection?'
Correct Answer: B
Rationale: Reflecting the client’s guilt validates emotions and encourages discussion, a therapeutic approach. Questioning causation, dismissing behavior, or suggesting AIDS testing is less supportive.
The client had a mastectomy for cancer of the breast and asks the nurse about a TRAM flap procedure. Which information should the nurse explain to the client?
- A. The surgeon will insert a saline-filled sac under the skin to simulate a breast.
- B. The surgeon will pull the client's own tissue under the skin to create a breast.
- C. The surgeon will use tissue from inside the mouth to make a nipple.
- D. The surgeon can make the breast any size the client wants the breast to be.
Correct Answer: B
Rationale: TRAM flap uses abdominal tissue for breast reconstruction. Saline sacs describe implants, mouth tissue isn’t used for nipples, and breast size is limited by available tissue.
To determine the significance of the client's symptomatic bleeding, which questions are most important for the nurse to ask? Select all that apply.
- A. Has your energy level changed remarkably?
- B. Do you have intercourse more than once a week?
- C. How many sanitary pads do you use?
- D. Is the bleeding light or dark red?
- E. Do you have itching and swelling of the labia?
- F. Have you lost weight in the past few months?
Correct Answer: A,C,D,F
Rationale: Energy level, pad usage, bleeding color, and weight loss assess the severity and impact of heavy bleeding, indicating potential anemia or underlying pathology.
If the client chooses to perform breast self-examination (BSE), which statement demonstrates the best understanding of when BSE should be performed?
- A. I will perform a BSE on a weekly basis.
- B. I will perform a BSE every 6 months.
- C. I will perform a BSE 1 week before my period begins.
- D. I will perform a BSE 3 to 7 days after my period ends.
Correct Answer: D
Rationale: BSE is best performed 3 to 7 days after the menstrual period ends when breasts are least likely to be tender or swollen, ensuring a more accurate examination.
The nurse discusses healthy sexual behaviors with the client. Which risk factor predisposes the client to acquiring a sexually transmitted infection?
- A. Experiencing early puberty
- B. Finding sex information on the Internet
- C. Having multiple sexual partners
- D. Receiving limited sex education
Correct Answer: C
Rationale: Multiple sexual partners increase exposure to STIs, significantly raising infection risk.