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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.
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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 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.
Which comment indicates that the client lacks a clear understanding of syphilis?
- A. I need to take my antibiotic for several months.
- B. My sex partner should be tested for the disease.
- C. Syphilitic lesions may be present in my partner's vagina.
- D. One infection provides lifelong immunity.
Correct Answer: D
Rationale: Syphilis does not confer lifelong immunity; reinfection is possible, indicating a misunderstanding by the client.
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.
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.