Nokea
Which intervention should the nurse include when teaching the client who is having an anterior colporrhaphy to repair a cystocele?
- A. Discuss the need to perform perineal care every four (4) hours.
- B. Discuss the care of an indwelling catheter for at least one (1) month.
- C. Instruct the client how to care for the pessary inserted in surgery.
- D. Teach the client how to perform Kegel exercises.
Correct Answer: D
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding recovery and preventing recurrence post-anterior colporrhaphy. Perineal care frequency is excessive, catheters are temporary, and pessaries are not used surgically.
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If this client is typical of others with this condition, she will most likely report to the nurse that she experiences urinary incontinence during which time?
- A. When sitting
- B. As she walks
- C. During sleep
- D. Upon sneezing
Correct Answer: D
Rationale: A cystocele causes stress incontinence, with urine leakage during activities that increase abdominal pressure, such as sneezing.
The client states that she examines her breasts in the shower and while lying down. The nurse recommends that the client should also inspect her breasts from which position?
- A. Bending from the waist
- B. Standing before a mirror
- C. Arching the back
- D. Leaning from side-to-side
Correct Answer: B
Rationale: Standing before a mirror allows the client to visually inspect both breasts for changes in size, shape, or skin texture, which is a key component of breast self-examination (BSE).
Which nursing task could be delegated to the unlicensed assistive personnel (UAP) for the client who had a total vaginal hysterectomy?
- A. Observe the color and amount of drainage on the client's perineal pad.
- B. Maintain a current intake and output for the client each shift.
- C. Provide the client with a plan of pharmacological pain management.
- D. Prepare the client for her discharge scheduled for the next day.
Correct Answer: B
Rationale: Maintaining intake and output is within UAP scope, involving measurement and recording. Observing drainage requires assessment, pain management involves nursing judgment, and discharge preparation includes teaching, all inappropriate for delegation.
If the client experiences all of the following signs and symptoms after the laparoscopy, which one can the nurse attribute directly to the endoscopic procedure?
- A. Nausea and vomiting
- B. Shoulder discomfort
- C. Urinary frequency
- D. Leg cramps
Correct Answer: B
Rationale: Shoulder discomfort is a common post-laparoscopy symptom due to residual carbon dioxide gas irritating the diaphragm.
The client who is four (4) months pregnant finds a lump in her breast and the biopsy is positive for Stage II cancer of the breast. Which treatment should the nurse anticipate the HCP recommending to the client?
- A. A lumpectomy to be performed after the baby is born.
- B. A modified radical mastectomy.
- C. Radiation therapy to the chest wall only.
- D. Chemotherapy only until the baby is born.
Correct Answer: D
Rationale: In pregnancy, chemotherapy is often used for Stage II breast cancer after the first trimester to control disease while minimizing fetal risk. Lumpectomy or mastectomy is delayed until after delivery, and radiation is avoided during pregnancy.