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What special instruction concerning the technique for taking vital signs is most important when assigning this task to a nursing assistant?
- A. Count the client's respirations while he is resting.
- B. Assess the client's pulse at the radial site.
- C. Take the client's blood pressure with an electronic machine.
- D. Avoid taking a rectal temperature.
Correct Answer: D
Rationale: Avoiding rectal temperature measurement prevents trauma or infection in a client with a suprapubic prostatectomy and catheters.
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The occupational health nurse is preparing a class regarding sexually transmitted diseases (STDs) for employees at a manufacturing plant. Which high-risk behavior information should be included in the class information?
- A. Engaging in oral or anal sex decreases the risk of getting an STD.
- B. Using a sterile needle guarantees the client will not get an STD.
- C. The more sexual partners, the greater the chance of developing an STD.
- D. If a condom is used, the client will not get a sexually transmitted disease.
Correct Answer: C
Rationale: Multiple sexual partners increase STD risk due to greater exposure. Oral/anal sex carries risk, sterile needles prevent bloodborne STDs but not others, and condoms reduce but don’t eliminate risk.
The client is diagnosed with primary syphilis. Which symptoms should the nurse observe?
- A. A chancre sore in the perineal area.
- B. A rash on the trunk and extremities.
- C. Blistering of the palms of the hands.
- D. Confusion and disorientation.
Correct Answer: A
Rationale: Primary syphilis presents with a painless chancre sore at the infection site. Rash is secondary, blisters are herpes-related, and confusion is tertiary.
The nurse is caring for a client with epididymitis secondary to a chlamydia infection. Which discharge instruction should the nurse discuss?
- A. The sexual partner must be prescribed antibiotics.
- B. Delay sexual intercourse for a minimum of three (3) months.
- C. Expect the urine to have white clumps for one (1) to two (2) months.
- D. Drainage from the scrotum is fine as long as there is no fever.
Correct Answer: A
Rationale: Chlamydia-related epididymitis requires partner treatment to prevent reinfection. Prolonged abstinence, white clumps in urine, and scrotal drainage are not expected.
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.
When the client asks where the laparoscope will be inserted, the nurse correctly identifies which structure?
- A. Abdomen
- B. Vagina
- C. Uterine cervix
- D. Uterine fundus
Correct Answer: A
Rationale: For endometriosis, a laparoscope is inserted through a small abdominal incision to visualize and remove ectopic tissue.