Nokea
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.
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The client diagnosed with endometriosis experiences pain rated a '5' on a 1-to-10 pain scale during her menses. Which intervention should the nurse teach the client?
- A. Teach the client to take a stool softener when taking morphine, a narcotic.
- B. Instruct the client to soak in a tepid bath for 30 to 45 minutes when the pain occurs.
- C. Explain the need to take the nonsteroidal anti-inflammatory drugs with food.
- D. Discuss the possibility of a hysterectomy to help relieve the pain.
Correct Answer: C
Rationale: NSAIDs are first-line for endometriosis pain, taken with food to prevent GI upset. Morphine is excessive, tepid baths are less effective, and hysterectomy is a last resort.
The nurse is assessing a client with rule-out testicular cancer. Which assessment data support the client having testicular cancer?
- A. The client complains of pain when urinating.
- B. There is a chancre sore on the shaft of the penis.
- C. The client complains of heaviness in the scrotum.
- D. There is a red, raised rash on the testes.
Correct Answer: C
Rationale: Heaviness in the scrotum is a classic symptom of testicular cancer due to tumor mass. Dysuria, chancre sores, and rashes are unrelated or indicative of other conditions (e.g., STDs).
Which could be a complication of cryotherapy surgery for cancer of the prostate?
- A. The urethra could become scarred and cause retention.
- B. The client could have ejaculation difficulties and be impotent.
- C. Bone marrow suppression could occur from the chemotherapy.
- D. Chronic vomiting and diarrhea causing electrolyte imbalance could occur.
Correct Answer: A
Rationale: Cryotherapy can scar the urethra, leading to urinary retention. Ejaculation issues are possible but less specific, and bone marrow suppression or GI issues are chemotherapy-related, not cryotherapy.
The nurse is teaching a class on Breast Health Awareness. Which are the American Cancer Society’s recommended guidelines for the performance of breast self-examination (BSE)? List in order of recommended performance.
- A. Visualize the breast from the front while standing before a mirror.
- B. Gently squeeze the nipple to express any fluid.
- C. Turn to each side and view each breast in the mirror.
- D. Palpate each breast in a circular motion while lying on the back.
- E. Palpate each breast in a circular motion while in the shower.
Correct Answer: A,C,D,E,B
Rationale: ACS BSE steps: 1) Front mirror visualization; 2) Side visualization; 3) Lying palpation; 4) Shower palpation; 5) Nipple check for discharge.
A nurse has been asked to teach ovulation and menstruation to a class of secondary school students. Place the events listed below in the order in which they occur in the menstrual cycle after menstrual flow ends. Use all the options.
- A. Ovum is released.
- B. Progesterone decreases.
- C. Endometrium begins to thicken.
- D. Ovarian follicle matures.
- E. Endometrium is shed.
- F. Corpus luteum forms.
Correct Answer: C,D,A,F,B,E
Rationale: After menstruation, the sequence is: endometrium thickens (follicular phase), ovarian follicle matures, ovum is released (ovulation), corpus luteum forms, progesterone decreases (if no pregnancy), and endometrium is shed (next menstruation).