Nokea
Unless the physician specifies otherwise, what is the maximum volume of urine the nurse should remove with the catheter at this time?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 2,000 mL
Correct Answer: B
Rationale: Removing up to 1,000 mL prevents bladder decompression injury, balancing the need to relieve retention with the risk of hypotension or hematuria.
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The nurse is admitting a client diagnosed with Stage Ia cancer of the cervix to an outpatient surgery center for a conization. Which data would the client most likely report?
- A. Diffuse watery discharge.
- B. No symptoms.
- C. Dyspareunia.
- D. Intense itching.
Correct Answer: B
Rationale: Stage Ia cervical cancer is often asymptomatic, detected via Pap smear or biopsy. Watery discharge, dyspareunia, and itching are more associated with advanced stages or infections.
The client is eight (8) hours post-transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time?
- A. Control postoperative pain.
- B. Assess abdominal dressing.
- C. Encourage early ambulation to prevent DVT.
- D. Monitor fluid and electrolyte balance.
Correct Answer: D
Rationale: Fluid and electrolyte balance is critical post-TURP due to irrigation and bleeding risks (e.g., hyponatremia). Pain, dressings, and ambulation are important but secondary.
The nurse is formulating a care plan for a client post-abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication?
- A. Potential for urinary retention.
- B. Potential for nerve damage.
- C. Potential for intestinal obstruction.
- D. Potential for fluid imbalance.
Correct Answer: C
Rationale: Intestinal obstruction is a common complication post-abdominal hysterectomy due to adhesions or ileus. Urinary retention and fluid imbalance are risks but less specific, and nerve damage is rare.
The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach?
- A. Don't lift more than five (5) pounds with the left hand until released by the HCP.
- B. The cancer has been totally removed and no follow-up therapy will be required.
- C. The client should empty the Hemovac drain about every 12 hours.
- D. The client should arrange an appointment with a plastic surgeon for reconstruction.
Correct Answer: A
Rationale: Limiting lifting with the affected arm prevents strain and lymphedema risk post-wedge resection. Claiming cancer is fully removed is misleading, Hemovac drains are uncommon in lumpectomy, and reconstruction is not universally needed.
The female client has a mother who died from ovarian cancer and a sister diagnosed with ovarian cancer. Which recommendations should the nurse make regarding early detection of ovarian cancer?
- A. The client should consider having a prophylactic bilateral oophorectomy.
- B. The client should have a transvaginal ultrasound and a CA-125 laboratory test every six (6) months.
- C. The client should have yearly magnetic resonance imaging (MRI) scans.
- D. The client should have a biannual gynecological examination with flexible sigmoidoscopy.
Correct Answer: B
Rationale: High familial risk warrants transvaginal ultrasound and CA-125 every 6 months for early detection. Prophylactic oophorectomy is a personal choice, MRI is not standard, and sigmoidoscopy is unrelated.