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Which staff nurse is best suited to care for a client with a radioactive implant?
- A. A male nurse with oncology nursing experience
- B. A female nurse who has had a hysterectomy
- C. A male nurse whose mother died of cancer
Correct Answer: A
Rationale: Oncology experience equips the nurse to safely manage a client with a radioactive implant, regardless of gender or personal history.
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The client is diagnosed with a rectovaginal fistula which is to be managed medically. Which information should the nurse teach the client prior to discharge?
- A. Douche with normal saline.
- B. Eat a low-residue diet.
- C. Keep ice packs to the area.
- D. Use an abdominal binder.
Correct Answer: B
Rationale: A low-residue diet reduces fecal output, aiding healing of a rectovaginal fistula. Douching risks infection, ice packs are ineffective, and binders are unrelated.
The nurse writes a client problem of 'anxiety related to potential sexual dysfunction' for a client diagnosed with cancer of the prostate. Which intervention should the nurse implement?
- A. Tell the client to discuss his fears with the HCP.
- B. Talk to the wife about the client’s concerns.
- C. Inform the client sexual functioning will not be altered.
- D. Provide a private area for the client to discuss his concerns.
Correct Answer: D
Rationale: A private area facilitates open discussion of sexual dysfunction fears, reducing anxiety. HCP referral, spousal discussion, or false reassurance are less therapeutic.
Before the physician performs the vaginal examination, which nursing intervention is most important?
- A. Arrange to have a female nurse present during the examination.
- B. Instruct the client on the dangers of cervical cancer.
- C. Palpate the internal organs to obtain a baseline assessment.
- D. Encourage the client to instill a vaginal lubricant.
Correct Answer: A
Rationale: Having a female nurse present ensures the client's comfort and adheres to ethical standards, providing a chaperone during the examination.
Which breast palpation technique is most correct?
- A. Examine the breast while using the heel of the hand.
- B. Examine the breast while using the index finger only.
- C. Examine the breast while using the index finger and thumb.
- D. Examine the breast while using the pads of the fingertips.
Correct Answer: D
Rationale: Using the pads of the fingertips allows for better sensitivity to detect lumps or changes in breast tissue during palpation, making it the most effective technique for BSE.
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.