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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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The nurse is assessing the client diagnosed with a rectocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Rectal pressure.
- B. Flatus.
- C. Fecal incontinence.
- D. Constipation.
- E. Urinary frequency.
Correct Answer: A,B,C,D
Rationale: Rectocele causes rectal pressure, flatus, fecal incontinence, and constipation due to posterior vaginal wall protrusion. Urinary frequency is more associated with cystocele.
Which breast palpation technique is most correct?
- A. Examine the breast while using the heel of the hand.
- B. Examine the breast while using the index finger only.
- C. Examine the breast while using the index finger and thumb.
- D. Examine the breast while using the pads of the fingertips.
Correct Answer: D
Rationale: Using the pads of the fingertips allows for better sensitivity to detect lumps or changes in breast tissue during palpation, making it the most effective technique for BSE.
To accurately determine the dosage of antineoplastic drugs, which information is essential to obtain from the client's chart?
- A. Urine output for the past 24 hours
- B. Body weight and height
- C. Date of surgery
- D. Drug allergies
Correct Answer: B
Rationale: Body weight and height are used to calculate body surface area, which determines accurate dosing of antineoplastic drugs.
The nurse correctly teaches a couple that immediately after a vasectomy, it is best to continue using an alternative birth control method for which time period?
- A. 1 month
- B. 6 weeks
- C. 12 weeks
- D. 6 months
Correct Answer: C
Rationale: Sperm may remain in the vas deferens for up to 12 weeks post-vasectomy, requiring alternative contraception until azoospermia is confirmed.
When the client asks how this condition will affect him sexually, which response by the nurse is most appropriate?
- A. It most likely will have little effect on your masculinity.
- B. It means that you will probably be impotent.
- C. You may notice that your breasts will enlarge later.
- D. Your sex drive will not be like that of other boys.
Correct Answer: A
Rationale: An undescended testicle, if corrected, typically has minimal impact on sexual function or masculinity, especially if addressed early.