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What information provided by the nurse is most appropriate for the client who plans on douching twice a week?
- A. A nonprescented solution of vinegar and water.
- B. Avoid frequent douching because it removes helpful microorganisms.
- C. Instill no more than 16 oz of irrigant solution with each douching.
- D. Discontinue the instillation if cramping occurs.
Correct Answer: B
Rationale: Frequent douching disrupts the vaginal flora, increasing infection risk, so the nurse should advise against it to maintain vaginal health.
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The client has an infected Bartholin’s cyst and the HCP has performed an incision and drainage (I&D) of the area. Which discharge instructions should the nurse teach the client?
- A. Complete all antibiotics as ordered.
- B. Report any drainage immediately.
- C. Keep all water away from the area.
- D. Lie prone as much as possible.
Correct Answer: A
Rationale: Completing antibiotics prevents recurrence of infection post-I&D. Drainage is expected, water avoidance is impractical, and prone positioning is unnecessary.
The client diagnosed with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement? Select all that apply.
- A. Place the client in a private room.
- B. Wear a dosimeter when entering the room.
- C. Encourage visitors to come and stay with the client.
- D. Plan to spend extended time with the client.
- E. Notify the nuclear medicine technician.
Correct Answer: A,B
Rationale: Brachytherapy requires a private room and dosimeter use to minimize radiation exposure. Visitors are limited, extended nurse time is avoided, and nuclear medicine notification is unnecessary.
The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement first?
- A. Catheterize the client to determine the amount of residual.
- B. Encourage the client to assume a normal position for urinating.
- C. Teach the client to use the Valsalva maneuver to empty the bladder.
- D. Determine the client’s normal voiding pattern.
Correct Answer: A
Rationale: Catheterization assesses residual urine, confirming retention and guiding treatment in advanced prostate cancer. Positioning, Valsalva, and voiding patterns are secondary.
What intervention should the nurse implement for a client diagnosed with a rectocele?
- A. Limit oral intake to decrease voiding.
- B. Encourage a low-residue diet.
- C. Administer a stool softener daily.
- D. Arrange for the client to take sitz baths.
Correct Answer: C
Rationale: Stool softeners prevent straining during bowel movements, reducing rectocele pressure. Limiting intake is inappropriate, low-residue diets increase constipation risk, and sitz baths are less specific.
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.