Nokea
Which specific complication should the nurse assess for in the client with a uterine prolapse recovering from an anterior and posterior repair?
- A. Orthostatic hypotension.
- B. Atelectasis.
- C. Allen sign.
- D. Deep vein thrombosis.
Correct Answer: D
Rationale: Deep vein thrombosis is a significant risk post-pelvic surgery due to immobility and venous stasis. Orthostatic hypotension is unrelated, atelectasis is a respiratory risk, and Allen sign pertains to arterial occlusion.
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The nurse is assessing a 34-year-old female client with fibrocystic breasts. Which question should the nurse ask the client during the assessment?
- A. Are your breasts more tender during your period?'
- B. Have you ever developed an allergy to chocolate?'
- C. Can you tell me more about your feelings of having fibrocystic breast changes?'
- D. Have you considered having a prophylactic mastectomy?'
Correct Answer: A
Rationale: Fibrocystic breast changes cause cyclical tenderness, worse premenstrually; this question assesses symptoms. Chocolate allergies, feelings, and prophylactic mastectomy are irrelevant.
Which nursing order is most appropriate to add to the client's initial postoperative care plan?
- A. Connect the cystostomy tube to a leg bag for drainage.
- B. Secure the cystostomy tube to the client's thigh.
- C. Ensure that the cystostomy tube is unclamped at all times.
- D. Clamp the indwelling catheter when the cystostomy tube is irrigated.
Correct Answer: C
Rationale: Keeping the cystostomy tube unclamped ensures continuous drainage, preventing complications like infection or pressure buildup.
Which statement is most accurate when discussing hair loss with the client?
- A. The hair loss is permanent, but attractive wigs are available.
- B. The hair loss is permanent, but hair transplantation is a possible solution.
- C. The hair loss is temporary; hair may grow back in several years.
- D. The hair loss is temporary; hair will regrow after chemotherapy is finished.
Correct Answer: D
Rationale: Hair loss from chemotherapy is typically temporary, with regrowth occurring after treatment ends, usually within months.
An elderly woman is diagnosed with pelvic relaxation disorder secondary to age-related changes. Which medication should the nurse expect to administer?
- A. Estrogen, a hormone.
- B. Cervidil, a cervical ripening agent.
- C. Progesterone, a hormone.
- D. Pitocin, an oxytocic agent.
Correct Answer: A
Rationale: Estrogen strengthens pelvic tissues in postmenopausal women with pelvic relaxation. Cervidil and Pitocin are for labor, and progesterone is less effective for this condition.
The nurse is caring for a client who is one (1) day postoperative hysterectomy for cancer of the ovary. Which nursing interventions should the nurse implement? Select all that apply.
- A. Assess for calf enlargement and tenderness.
- B. Turn, cough, and deep breathe every six (6) hours.
- C. Assess pain on a 1-to-10 pain scale.
- D. Apply sequential compression devices to legs.
- E. Assess bowel sounds every four (4) hours.
Correct Answer: A,C,D,E
Rationale: Assess for DVT (calf tenderness), manage pain, use SCDs for DVT prevention, and monitor bowel sounds (ileus risk) are critical post-hysterectomy. Turning every 6 hours is too infrequent; every 2 hours is standard.