Nokea
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.
You may also like to solve these questions
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.
The outpatient clinic nurse is working with clients diagnosed with sexually transmitted diseases (STD). Which long-term complication should the nurse discuss with the clients about STDs?
- A. Stress the need for clients to completely finish all antibiotics prescriptions.
- B. Inform the clients that, legally, many STIs must be reported to the health department.
- C. Sexually transmitted diseases can result in reproductive problems.
- D. Discuss the myth that acquired immunodeficiency syndrome is an STI.
Correct Answer: C
Rationale: STDs like chlamydia and gonorrhea can cause infertility or ectopic pregnancy, a critical long-term complication. Antibiotic completion, reporting, and AIDS myths are important but not complications.
When the nurse does a physical assessment of this client, which technique is best for determining the extent of the prolapse?
- A. Examine the perineum when the client rolls from side to side.
- B. Examine the perineum as the client stands and bears down.
- C. Examine the perineum with the client in a dorsal recumbent position.
- D. Examine the perineum with a lubricated speculum and flashlight.
Correct Answer: B
Rationale: Standing and bearing down makes a prolapsed uterus more visible, allowing accurate assessment of its extent.
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.