Nokea
When collecting a specimen from the client who may have gonorrhea, which nursing action is correct?
- A. Wearing latex gloves
- B. Using a disinfectant
- C. Asking the client to provide the specimen
- D. Refrigerating the specimen immediately
Correct Answer: A
Rationale: Wearing latex gloves protects the nurse from exposure to infectious material during specimen collection.
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The nurse is working in a health clinic. Which disease is required to be reported to the public health department?
- A. Pelvic inflammatory disease.
- B. Epididymitis.
- C. Syphilis.
- D. Ectopic pregnancy.
Correct Answer: C
Rationale: Syphilis is a reportable STD to track and control spread, per public health regulations. PID, epididymitis, and ectopic pregnancy are not typically reportable.
Which assessment findings recorded by the nurse indicate high risk factors for developing breast cancer? Select all that apply.
- A. The client began menstruating before age 12.
- B. The client had three full-term pregnancies.
- C. The client has a very large breast.
- D. The client has had radiation treatment to the chest.
- E. The client has had breast implants.
Correct Answer: A,D
Rationale: Early menarche (before age 12) and chest radiation exposure are established risk factors for breast cancer due to prolonged estrogen exposure and DNA damage, respectively. Multiple pregnancies reduce risk, and breast size or implants are not significant risk factors.
If the client is asymptomatic and at low risk for breast cancer, the nurse would be correct in advising her to have a baseline mammogram at what age?
- A. 35
- B. 45
- C. 50
- D. 55
Correct Answer: C
Rationale: The American Cancer Society recommends that women at average risk for breast cancer begin annual mammograms at age 45, but a baseline mammogram may be considered at age 40-50 depending on guidelines. For low-risk, asymptomatic women, age 50 is often the standard starting point for routine screening.
Which nursing interventions are most appropriate to add to the client's immediate postoperative care plan? Select all that apply.
- A. Elevate the affected arm to reduce swelling.
- B. Monitor for signs of infection at the surgical site.
- C. Encourage early ambulation to prevent complications.
- D. Administer prescribed pain medications as needed.
- E. Teach the client to avoid using the affected arm for 6 weeks.
Correct Answer: A,B,C,D
Rationale: Elevating the arm reduces lymphedema risk, monitoring for infection ensures early detection, ambulation prevents complications like thrombosis, and pain management promotes comfort. Restricting arm use for 6 weeks is excessive and not standard.
The client is diagnosed with metastatic prostate cancer to the bones. Which nursing intervention should the nurse implement?
- A. Prepare for a transurethral resection of the prostate.
- B. Keep the foot of the bed elevated at all times.
- C. Place the client on a scheduled bowel regimen.
- D. Discuss the client’s altered sexual functioning.
Correct Answer: C
Rationale: Bone metastasis increases constipation risk (e.g., from analgesics); a bowel regimen prevents complications. TURP is for obstruction, bed elevation is irrelevant, and sexual function is secondary.