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The patient who had a colporrhaphy for the repair of a cystocele and rectocele asks that the catheter be removed as it is bothersome to her. In which way will the nurse explain the reason for the catheter?
- A. It replaces uncomfortable gauze packing.
- B. It will prevent adhesions and will be in place for about 2 weeks.
- C. It allows for quick urine sample collection.
- D. It keeps the bladder empty and prevents stress on the sutures.
Correct Answer: D
Rationale: A retention catheter is usually inserted into the bladder to keep it empty and prevent pressure on sutures.
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The nurse gives discharge instructions to a person who has had a modified radical mastectomy of the right side to perform the 'elbow pull-in.' Which step is the first step of the exercise?
- A. Pull elbows forward until they touch.
- B. Lower and straighten the arms.
- C. Extend arms sideways to shoulder level.
- D. Bring elbows back and extend arms.
- E. Clasp hands behind neck.
Correct Answer: C
Rationale: The exercise requires that you bring the arms out at shoulder level, clasp hands behind head and bring elbows to touch, then bring elbows back and extend arms lower and straighten arms.
A patient, age 41, has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She asks the nurse if she will have 'hot flashes.' Knowledge of which fact will guide the nurse's response?
- A. Only the uterus was removed, and the ovaries are still producing estrogen and she will not have hot flashes.
- B. The patient is too young to have hot flashes associated with menopause.
- C. The uterus, ovaries, and fallopian tubes were removed, and she will have surgically induced menopause and may have hot flashes.
- D. The uterus and fallopian tubes were removed, and she will not experience 'hot flashes.'
Correct Answer: C
Rationale: A total abdominal hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, fallopian tubes, and ovaries. If the ovaries are removed in these surgeries, the surgery will induce menopause and hot flashes may occur.
Which statement indicates that the patient who has had an abdominal hysterectomy needs further home teaching?
- A. I understand I can lift as much as 20 lb.'
- B. I'm leaving today to stay with my daughter who lives 20 miles away. My husband plans to drive the family car.'
- C. The health care provider said I can't have sexual intercourse for 4 to 6 weeks.'
- D. I'm going to miss wearing my girdle or knee-high hose.'
Correct Answer: A
Rationale: If there has been an abdominal incision, there may be further restrictions on heavy lifting (nothing over 10 lb).
At which stage of life should a male be taught testicular self-examination (TSE)?
- A. childhood
- B. pre-adolescent
- C. puberty
- D. middle age adult
Correct Answer: C
Rationale: Young men should be taught to perform TSE monthly beginning at puberty.
Which instruction will a nurse give a patient with genital herpes who does not have lesions at the present?
- A. Continued use of acyclovir will prevent reinfection by the virus.'
- B. Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.'
- C. Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.'
- D. Recurrent genital herpes is promoted by any sexual stimulation.'
Correct Answer: B
Rationale: Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent.