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The public health nurse is teaching young adolescents in a sexual health class the proper use of a condom. Which statements made by the students indicate teaching was successful? Select all that apply.
- A. Baby oil is an acceptable lubricant.
- B. Ensure a tight fit of the condom.
- C. Only use latex condoms.
- D. Place the condom on an erect penis.
- E. Store the condoms in a cool dry place.
- G. C,D,E
Correct Answer: Latex condoms are effective against STIs and pregnancy, unlike natural skin condoms. Condoms should be applied on an erect penis to prevent slippage, and stored in a cool, dry place to avoid damage. Baby oil degrades latex, and a tight fit increases breakage risk.
Rationale:
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To assist the woman in regaining control of the urinary sphincter after bladder surgery, the nurse should teach the client to perform which action?
- A. Limit the intake of fluid.
- B. Void every hour while awake.
- C. Perform Kegel exercises daily.
- D. Take a laxative every night.
- G. C
Correct Answer: Kegel exercises strengthen pelvic floor muscles, improving urinary sphincter control. Limiting fluids risks dehydration, frequent voiding may irritate the bladder, and laxatives address constipation, not sphincter control.
Rationale:
A nurse is working with a woman who has been diagnosed with severe fibrocystic breast disease. After describing the medications that can be used as treatment, the nurse determines that additional teaching is needed when the client identifies which drug as being used?
- A. Danazol
- B. Penicillin
- C. Bromocriptine
- D. Tamoxifen
- G. B
Correct Answer: Penicillin, an antibiotic, has no role in treating fibrocystic breast disease, which involves hormonal changes. Danazol, bromocriptine, and tamoxifen are used to manage symptoms by altering hormone levels.
Rationale:
A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet on the client's right arm. Which action by the nurse would be most appropriate?
- A. Call the surgeon to perform a femoral puncture.
- B. Assist in holding the client's arm still.
- C. Tell the technician to obtain the blood sample from the client's left arm.
- D. Suggest a finger stick be done on one of the client's left fingers.
- G. C
Correct Answer: Using the left arm avoids risks like lymphedema in the surgical arm. Femoral puncture is invasive, assisting with the right arm is harmful, and finger sticks are inadequate for CBC.
Rationale:
A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?
- A. The social worker
- B. The nurse
- C. The physician
- D. The unit secretary
- G. C
Correct Answer: The physician is legally responsible for obtaining informed consent, explaining the procedure's purpose, risks, and alternatives. Nurses may assist, but social workers and unit secretaries have no role in this process.
Rationale:
A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives.
- A. A 26-year-old client who has migraine headaches at the start of each menstrual cycle
- B. A 28-year-old client who has a history of pelvic inflammatory disease
- C. A 32-year-old client who has benign breast disease
- D. A 38-year-old client who reports smoking one pack of cigarettes every day
- G. D
Correct Answer: Smoking, especially over age 35, increases cardiovascular risks with oral contraceptives, making it a contraindication. Migraines, PID history, and benign breast disease are not absolute contraindications.
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