MDC3 Exam 1

NCLEX Examination Challenge 67.1 Physiological Integrity A client has continuous bladder irrigation after surgery yesterday. The amount of bladder irrigating solution that has infused over the past 12 hours is 1100 mL. The amount of fluid in the urinary drainage bag is 1950 mL. The nurse records that the client had ________ mL urinary output in the past 12 hours. Fill in the blank.

850mL

NCLEX Examination Challenge 69.2 Physiological Integrity Which teaching will the nurse provide to a client who has been prescribed antibiotics for pelvic inflammatory disease (PID)? Select all that apply. A. "Finish all of the prescribed drug even if you begin to feel better." B. "If you feel nauseated from the antibiotics, take a dose of Tums or Maalox." C. "Take antibiotics with food to decrease the chance of stomach irritation." D. "You may resume intercourse once you have been on the antibiotic for 48 hours." E. "You will need to return to see the health care provider after finishing drug therapy."

A. "Finish all of the prescribed drug even if you begin to feel better." E. "You will need to return to see the health care provider after finishing drug therapy."

CH 68 1. The nurse is caring for a client who reports beginning to transition from male to female. Which nursing action is appropriate regarding pronoun use? A. Ask the patient which pronouns are preferred and use those. B. Implement use of "he/him" pronouns as the client's natal sex is male. C. Use "Miss" or" Mrs.," since the client has begun the transition to female. D. Document that male or female pronouns are appropriate to use at this time.

A. Ask the patient which pronouns are preferred and use those.

NCLEX Examination Challenge 65.2 Health Promotion and Maintenance When caring for a 28-year-old healthy client, how frequently does the nurse recommend a clinical breast examination (CBE)? A. Every 3 years B. At each annual physical C. Not until age 30, as the risks are low D. To begin at age 40 when risks increase

A. Every 3 years

NCLEX Examination Challenge 64.3 Physiological Integrity The nurse is caring for a client who underwent a hysterosalpingogram earlier in the day. Which assessment finding will the nurse immediately report to the health care provider? Select all that apply. A. Fever and chills B. Heart rate 120 beats/min C. Bloody vaginal discharge D. Pain in the lower quadrant E. Discomfort in the shoulder

A. Fever and chills B. Heart rate 120 beats/min D. Pain in the lower quadrant

NCLEX Examination Challenge 66.2 Safe and Effective Care Environment A client is scheduled for a transvaginal surgical repair this morning. Which assessment finding requires immediate nursing intervention? A. Notation of surgery type with mesh B. Expression of fear prior to procedure C. Blood pressure 140/92 mm Hg, P 88, R 20, T 98.8°F D. Client request for caregiver to come to PACU

A. Notation of surgery type with mesh

NCLEX Examination Challenge 65.3 Physiological Integrity The nurse has delegated care for a client with a radical left mastectomy for breast cancer to assistive personnel (AP). Which AP action requires nursing intervention? Select all that apply. A. Obtains blood pressure via left arm B. Reports client's pain level to the nurse C. Applies gait belt prior to walking with the client D. Records vital signs in the electronic health record E. Assists client to administer patient-controlled analgesia

A. Obtains blood pressure via left arm E. Assists client to administer patient-controlled analgesia

2. A client who is scheduled for a Pap smear reports having had sexual intercourse 1 day prior and douching afterward. What is the appropriate nursing action? A. Reschedule the Pap smear for another week B. Delay the procedure until later in the afternoon C. Help the client prepare for the procedure at this time D. Hold the procedure until the client's next menstrual cycle

A. Reschedule the Pap smear for another week Teach women not to douche, use vaginal medications, powders, or deodorants, or have sexual intercourse for at least 24 hours before the test, because these may interfere with test interpretation.

Ch 69 1. The nurse hears a patient tell her partner that condoms with spermicide are important to protect themselves from sexually transmitted infections (STIs). What is the appropriate nursing response? A. Teach that spermicide has not been shown to be effective in STI prevention. B. Do nothing because the nurse should not be listening to the client's conversation. C. Educate that spermicide must be used with water-based lubricant to be effective. D. Affirm that spermicide helps to block transfer of sexually transmitted organisms.

A. Teach that spermicide has not been shown to be effective in STI prevention.

A 70-year-old man reports difficulty with starting a urine stream and dribbling after urination. 1.What questions will the nurse ask when taking the client's history?

ANS: Ask the patient about urinary pattern, frequency, nocturia, and changes in the force and size of the urinary stream. Ask about blood in the urine—BPH is a common cause of hematuria in older men

The nurse is caring for a client who has been recently diagnosed with fibrocystic breast condition. What teaching will the nurse provide? A.Use analgesics for pain control B.Eat yogurt to increase calcium intake C.To be comfortable, do not wear a bra at home D.Increase salt intake before menses each month

ANS: A Analgesics may decrease pain for clients who have FBC. Dairy and salt intake should be discouraged. Wearing a bra at all times can increase comfort.

A client with end-stage kidney disease (ESKD) has this serum laboratory analysis: K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL What is the priority nursing intervention? A.Assess heart rate and rhythm. B.Implement seizure precautions. C.Assess the client's respiratory status. D.Evaluate the client's acid-base balance.

ANS: A Clients with ESKD experience significant fluid and electrolyte imbalances that are managed with medications and dialysis. Hyperkalemia can be a life-threatening event. In clients with kidney disease, the myocardial response (heart rate and rhythm) to hyperkalemia should be assessed to effectively determine appropriate treatment. High sodium can increase the client's risk for seizures, excessive fluid balance will negatively effect breathing, and clients with ESKD experience acid-base imbalances from an inability to synthesize bicarbonate.

The nurse is caring for four clients. Which client does the nurse identify that is likely experiencing stress incontinence? A.Client who laughs and cannot retain urine B.Client who feels an urge to urinate and immediately does so C.Client who has dementia and does not understand how to toilet D.Client who has not voided in 12 hours and experiences minor leakage

ANS: A Stress incontinence is the most common type of urinary incontinence. It is characterized by the inability to retain urine when laughing, coughing, sneezing, jogging, or lifting. Client B likely has urge incontinence; Client C likely has overflow incontinence; Client D likely has functional incontinence.

A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. . Following dialysis, what assessment finding does the nurse anticipate? A.Weight increased after dialysis. B.Temperature higher following dialysis. C.Clotting studies reduced post-dialysis. D.Blood pressure higher than pre-dialysis.

ANS: A The client's temperature is elevated after dialysis because the dialysis machine warms the blood slightly. Weight and blood pressure should be decreased because excess fluid is removed during dialysis. Heparin is required during hemodialysis and increases clotting time.

A 20-year-old male client reports to the college health center, reporting burning upon urination. What priority question will the nurse ask? A."Are you sexually active?" B."Do you have low back pain?" C."How long have you had these symptoms?" D."Have you had a fever in the past 24 hours?"

ANS: A The most common cause of urethritis in men is sexually transmitted infections (STIs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tracts). Other questions can be asked after assessing sexual activity and possible STI exposure.

What teaching will the nurse provide to a client scheduled for a total abdominal hysterectomy? A.The client will no longer have a period. B.Vaginal drainage may be bloody for the first month. C.Proper nutrition must be consumed to avoid weight gain. D.This surgical procedure eliminates menopausal symptoms.

ANS: A The patient will no longer have a period after a total abdominal hysterectomy, and menopausal symptoms will be experienced since the ovaries are removed in this procedure. Although vaginal discharge may be present for a few days after discharge, it should not persist for a month. Weight gain is not associated with a hysterectomy.

The nurse is caring for four female clients. Which client does the nurse identify at the risk for breast cancer? A.28-year-old African-American with early menarche B.36-year old Asian-American with 3 children C.45-year-old Native American with family history of lung cancer D.50-year-old Caucasian American with ongoing menarche

ANS: A The rate of breast cancer in African-American women younger than 60 years is higher than for others in that age-group (Centers for Disease Control and Prevention [CDC], 2018). African-American women are also 40% more likely to die from breast cancer than white women (CDC). African-American women have the highest risk for triple-negative breast cancer (Anders & Carey, 2019). The other female clients do not have high risk factors.

The nurse is caring for a 24-year old female client who is menstruating reports running a temperature and aching for 2 days, and having "a sunburn". Which nursing action is appropriate? A.Contact the health care provider B.Apply aloe vera to the sunburned area C.Administer acetaminophen as prescribed D.Recommend increasing fluids and resting

ANS: A This client may be at risk for toxic shock syndrome. Symptoms include fever (which remains elevated despite treatment), diffuse macular rash (which often resembles a sunburn), myalgias, and hypotension. The health care provider must be notified, as TSS can lead to death if left untreated. All other options delay treatment and do not address the priority problem.

A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. As the client is preparing to discharge, the nurse will teach restrictions of which dietary elements? (Select all that apply.) A.Potassium B.Phosphorus C.Calcium D.Protein Vitamins

ANS: A, B, D Sodium is restricted because it causes retention of fluids. Potassium is restricted to prevent dangerous cardiac dysrhythmias. Vitamins must be supplemented, not restricted. There is an inverse relationship between phosphorus and calcium; when phosphorus is high, calcium is low and should not be restricted.

A 53-year-old perimenopausal female broke her wrist after falling from a ladder. She reports no health concerns other than intermittent fatigue, insomnia, and hot flashes. What assessment questions should the nurse ask? Select all that apply. A."What kind of exercise do you normally do?" B."Weren't you using caution on the ladder?" C."What kinds of foods you usually eat?" D."Are you currently taking any drugs or supplements?" E."Is there a family history of heart disease?"

ANS: A, C, D, E Healthy lifestyle habits can reduce the severity and incidence of perimenopausal symptoms. Routine exercise decreases bone loss and improves mood and cognitive function. Proper nutrition is also important in the management of blood sugar, weight, and treatment of bone calcium loss associated with menopause. It is also important to inquire about the cardiac history and medication history, including over-the-counter medications, when conducting a health history of a middle-aged woman. Asking about using caution on the ladder is inappropriate and would likely be perceived as rude.

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. 1. What factors place this client at risk for breast cancer? (List all that apply.)

ANS: Age is the primary risk factor for breast cancer. Additional risk factors include family history with first-degree relatives, nulliparity, smoking, and alcoholic consumption of two or more drinks per day.

The nurse is caring for a 23-year old client who reports abdominal pain, greenish vaginal discharge and dysuria. She has a mild fever. The client admits to smoking a pack of cigarettes daily. She reports having 3 current sexual partners, and discomfort during intercourse. The electronic health record indicates that she was treated for a gonococcal infection two years ago. Which findings does the nurse identify that indicate risk for pelvic inflammatory disease (PID)?

ANS: Age younger than 26; symptoms of abdominal pain, painful urination and intercourse, mild fever, and green discharge; multiple sexual partners; smoking; history of sexually transmitted disease

Six months later, the client returns because she has noticed a lump in her left breast. Upon examination, a small mass is palpated. A diagnostic mammogram is ordered and confirms the presence of a 2 × 3 cm mass. The client is scheduled for a surgical excisional biopsy. 3. What should the client be taught about this procedure?

ANS: An excisional biopsy removes the mass itself for histologic (cellular) evaluation for cancer.

The nurse is caring for four clients. Which client does the nurse identify at highest risk for acute pyelonephritis? A.18-year-old male with spinal cord injury B.24-year-old female with urinary reflux C.31-year-old male with HIV infection D.40-year-old female with urinary tract stones

ANS: B Acute pyelonephritis is most commonly seen in 20 to 30 year old female. Reflux is a key contributor. The conditions of other clients is characteristic of chronic pyelonephritis.

The nurse is caring for a 23-year old client who reports abdominal pain, greenish vaginal discharge and dysuria. She has a mild fever. The client admits to smoking a pack of cigarettes daily. She reports having 3 current sexual partners, and discomfort during intercourse. The electronic health record indicates that she was treated for a gonococcal infection two years ago. The client's vital signs are BP 120/68, HR 76/min, RR 18/min, T 101.9º F. Which assessment finding does the nurse identify that supports the diagnosis of PID? A.Heart rate 76/min B.Temperature 101.9º F C.Blood pressure 120/68 Respiratory rate 18/min

ANS: B An elevated temperature of >101° F or 38.3° C supports the diagnosis of PID.

The nurse is caring for a client with polycystic kidney disease. Which assessment finding requires immediate nursing intervention? A.Temperature of 99° F B.Blood pressure of 170/90 C.Heart rate of 100 beats/min Urine output of 40 cc/hr

ANS: B Clients with polycystic kidney disease often have high blood pressure. The cause of hypertension is related to kidney ischemia from the enlarging cysts. As the vessels are compressed and blood flow to the kidneys decreases, the renin-angiotensin system is activated, raising blood pressure. Control of hypertension is a top priority because proper treatment can disrupt the process that leads to further kidney damage. Other findings can be assessed after addressing hypertension.

Which statement by a transgender client requires immediate nursing intervention? A."I have lost so many friends through the years." B."Sometimes I don't feel like life is worth living." C."I'm almost certain I want to schedule gender-affirming surgery." D."My family doesn't understand my gender identity."

ANS: B Individuals who are transgender may be at risk for suicide due to numerous health disparities they have faced. Although they nurse will provide a response to any of these statements, the client statement that requires immediate nursing intervention is the one that indicates that the client may be at risk for suicide or have suicidal ideation.

The nurse is caring for a client who has just been prescribed sildenafil for erectile dysfunction. Which teaching will the nurse provide? A. Take one hour before intercourse B. Be cautious when standing up quickly C. Drink grapefruit juice when taking drug D. Perform handwashing before giving injection

ANS: B Phosphodiesterase-5 inhibitors can lower blood pressure so the nurse will teach the client to use caution when standing up quickly. This drug, which comes in pill form, must be taken approximately 15 minutes before intercourse and should not be taken with grapefruit juice.

Which assessment finding does the nurse anticipate for a client with chronic glomerulonephritis? (Select all that apply.) A.Increased urinary output B.Specific gravity of 1.010 C.Red blood cells in the urine D.Serum creatinine of 5 mg/dL Sodium level of 130 mEq/L

ANS: B, C Options B and C are expected findings in a client with chronic glomerulonephritis. This client would also have decreased urinary output, serum creatinine of < 6 mg/dL, and a sodium level of > 135 mEq/L. The other findings are not anticipated.

The nurse is caring for a 23-year old client who reports abdominal pain, greenish vaginal discharge and dysuria. She has a mild fever. The client admits to smoking a pack of cigarettes daily. She reports having 3 current sexual partners, and discomfort during intercourse. The electronic health record indicates that she was treated for a gonococcal infection two years ago. What teaching will the nurse provide when the client is being discharged to home? Select all that apply. A."You can return to work tomorrow." B."Check your temperature twice daily." C."Abstain from sexual intercourse at this time." D."Take all the medications as prescribed." E."Make an appointment for follow-up in several days."

ANS: B, C, D, E The patient should be instructed to get plenty of rest, check her temperature to be sure she is not developing further fever, abstain from intercourse until healed, take all medications as directed, and to follow up with her provider. She should remain off work until she is better.

A client with kidney failure whose pulse oximeter reading is 96% reports dyspnea. The nurse assesses that the client is visibly distressed, with a respiration rate of 32 breaths/minute. What is the appropriate nursing intervention? A.Notify the respiratory therapist. B.Contact the health care provider. C.Administer oxygen by nasal cannula. D.Elevate the head of bed to 90 degrees.

ANS: C Clients with kidney failure are anemic because they cannot produce the hormone erythropoietin. A high oxygen saturation in an anemic client who is showing signs of respiratory distress may still be hypoxemic. Clients who have decreased hemoglobin could have a high percentage of the hemoglobin saturated with oxygen, but because they have a decreased hemoglobin level, not enough oxygen is provided. Administering oxygen is necessary.

Which assessment finding in a client with AKI requires immediate nursing intervention? A.Heart rate of 120 beats/min B.Blood pressure of 156/88 C.Urine specific gravity of 1.001 mm Hg D.Intake of 2000 mL and output of 1500 mL in the past 24 hours

ANS: C Decreased urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage and early kidney failure. Normal urine specific gravity ranges from 1.002 to 1.028. Assessing the client's perfusion status is also very important in the prevention and/or treatment of kidney disease.

A 22-year-old sexually active male reports a low-grade fever and headache, and a rash on his hands. What condition does the nurse anticipate? A.HIV B.HPV C.Syphilis D. Gonorrhea

ANS: C Symptoms of secondary syphilis usually develop 6 weeks to 6 months after the onset of primary syphilis. During this stage, syphilis is a systemic disease because the spirochetes circulate throughout the bloodstream. Common signs and symptoms include malaise, low-grade fever, headache, muscular aches and pains, sore throat, and generalized rash (usually on the hands and feet).

A 22-year-old sexually active male reports a low-grade fever and headache, and a rash on his hands. What condition does the nurse anticipate? A.HIV B.HPV C.Syphilis Gonorrhea

ANS: C Symptoms of secondary syphilis usually develop 6 weeks to 6 months after the onset of primary syphilis. During this stage, syphilis is a systemic disease because the spirochetes circulate throughout the bloodstream. Common signs and symptoms include malaise, low-grade fever, headache, muscular aches and pains, sore throat, and generalized rash (usually on the hands and feet).

. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. The client's daughter asks why her mother must be weighted before and after the dialysis treatment. What is the appropriate nursing response? A."It is part of the protocol for dialysis." B."It ensures that she is getting adequate nutrition." C."It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis." D."It is essential for calculating the fluid restriction your mother will receive on non-dialysis days."

ANS: C The best way to estimate fluid and sodium retention and removal is by weighing the client.

The nurse is caring for a client who will soon receive a kidney transplant. When the client says, "what will I do if this transplant doesn't work?", what is the appropriate nursing response? A."Try to focus on getting through the surgery first." B."Kidney transplants are almost always successful." C."It sounds like you are concerned about the outcome of the procedure." D."If this transplant doesn't work, I'm sure there will be another donor soon."

ANS: C The nurse should allow the client to express his or her feelings; the client's question demonstrates concern—possibly anxiety or fear—and the nurse allows further exploration of those feelings by verbalizing the implied. Response B gives false reassurance; response D dismisses the client's feelings; response A does not address the client's feelings.

What does the nurse identify as an expected outcome when planning care for a client with genital herpes being treated with antiviral drugs? A.Eradication of the infection B.No chance of transmitting the virus to a partner C.Decrease in the severity and frequency of recurrent outbreaks D.Prevention of viral shedding even when the patient is asymptomatic

ANS: C There is no cure for genital herpes. Drugs can reduce the severity, promote healing, and decrease the frequency of recurrent outbreaks, but they cannot prevent viral shedding.

1. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment? A.Calcium B.Atenolol C.Glyburide D.Multivitamin

ANS: C Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.

The nurse has placed an indwelling urinary catheter via sterile technique into a client. The nurse recognizes that it is how long before bacterial colonization begins? A.12 hours B.24 hours C.48 hours 72 hours

ANS: C Within 48 hours of catheter insertion, bacterial colonization along the urethra and the catheter itself begins. Risks for infection associated with a catheter increases 3%-10% per day the catheter is in place (Ferguson, 2018).

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. What information will the nurse include when teaching this client about health promotion? (Select all that apply.) A.Mammograms are not effective in diagnosing breast cancer. B.An MRI of the breasts should be completed every year. C.Ask your provider to perform a clinical breast examination (CBE). D.Notify your provider if you notice changes in your breasts. E.Breast self-examination (BSE) is the best way to detect breast cancer early.

ANS: C, D Evidence shows that screening mammograms, clinical breast examinations, and breast self-awareness are the best approaches toward health promotion and maintenance for average-risk women. An MRI is not needed annually. Changes in breasts should be reported to the health care provider. BSE, for women who choose to practice this, can be performed to establish a baseline for breast familiarity, but it is not the best way to detect breast cancer early.

The nurse is assessing a female client with genital warts. What assessment finding does the nurse anticipate? A.Chancre B.No symptoms C.Abdominal pain D. Small flesh-colored growths

ANS: D A chancre is found in syphilis; gonorrhea may have no symptoms; PID is accompanied by abdominal pain

The nurse is assessing a female client with genital warts. What assessment finding does the nurse anticipate? A.Chancre B.No symptoms C.Abdominal pain D.Small flesh-colored growths

ANS: D A chancre is found in syphilis; gonorrhea may have no symptoms; PID is accompanied by abdominal pain

The nurse has been assigned to care a FtM client whose name is recorded as both Grace Kart and Grey Kart in the electronic health record. How will the nurse address the client? A."It's nice to meet you, Grace." B."How are you feeling today, Grey?" C."Ms. Kart, I will be your nurse today." D."My name is Kris. How would you like me to address you?"

ANS: D As with any patient, it is best to ask how he or she prefers to be addressed when during the nursing history and physical assessment. For example, for non-transgender patients, some people may go by a nickname or by their middle name and prefer to be addressed as such. For transgender patients, it is not uncommon for driver's licenses, insurance cards, and other forms of identification to retain their birth names (and by extension, birth sex) because it can be difficult to change this information, particularly if a person is in the process of transitioning. Therefore, nurses may receive patient documentation with misleading patient data. For example, a nurse may receive a health care record listing a male name and birth sex yet encounter a patient presenting as female in appearance. It can be offensive and embarrassing for the patient who clearly identifies as female to be called "Mister," "sir," or the male birth name. Not only does it communicate disrespect, it also signals to the patient that she may receive inadequate care or that the environment is unsafe.

What priority question will the nurse ask when taking a history of a client with BPH? A."Do you have high blood pressure?" B."Have you had a recent urinary tract infection?" C."Do you have a family history of kidney disease?" D."Do you have difficulty starting and continuing urination?"

ANS: D Benign prostatic hyperplasia (BPH) can lead to chronic urinary retention causing a backup of urine with gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis). These problems can lead to chronic kidney disease.

A MtF client has been prescribed feminizing drug therapy. Which assessment finding does the nurse anticipate? A.Male-pattern baldness B.Increase in muscle mass C.Redistribution of body fat D.Breast tissue development

ANS: D Feminizing drug therapy induces breast tissue development and reduces muscle mass. Masculinizing drug therapy induces male-pattern baldness and redistribution of body fat.

A client with a history of kidney disease is admitted with acute shoulder pain. Which order will the nurse discuss with the prescribing health care provider? A.Digoxin 0.125 mg by mouth daily B.Metoprolol 50 mg by mouth twice daily C.Pan cultures for a temperature >38.5º C D.Ibuprofen 800 mg by mouth every 4 hours

ANS: D High-dose or long-term use of nonsteroidal antiinflammatory drugs (NSAIDs) can seriously reduce kidney function, so the nurse will discuss this with the prescribing health care provider.

Which client does the nurse identify as most likely to experience renal compromise assessed by decreased urine production? A.12-year history of diabetes mellitus B.White blood cell count of 13,000/mm3 C.Recent history of myocardial infarction D.Blood pressure of 92/48 mm Hg for 12 hours

ANS: D The ability of the kidneys to self-regulate renal blood pressure and renal blood flow keeps the glomerular filtration rate (GFR) constant. A blood pressure of 92/48 mm Hg is a mean arterial pressure of 62 mm Hg. The kidney has a difficult time regulating GFR with a mean arterial blood pressure less than 65 mm Hg.

Pathologic examination of the removed breast lump tissue reveals malignancy. The client undergoes a modified radical mastectomy with lymph node dissection, which will be followed by radiation and chemotherapy. 4. What immediate postoperative intervention will the nurse implement? A.Check vital signs every four hours. B.Position the client supine to facilitate drainage. C.Instruct assistive personnel (AP) to avoid taking blood pressure (BP) in the client's right arm. D.Measure the Jackson-Pratt tube drainage and assess color and odor.

ANS: D The client's left breast was removed; the left arm is affected, so it should not have BPs, injections, or venipunctures performed on it. Those types of procedures should be performed on the right arm. Vital signs should be checked every 30 minutes twice, then every hour twice, and then every 4 hours. The client should be positioned with the head of the bed elevated at least 30 degrees to facilitate drainage. Drainage should be assessed for color and odor.

The nurse is caring for a client who just had a bilateral mastectomy. When the client states, "my partner is going to hate how I look", what is the appropriate nursing response? A."I'm sure your partner will be accepting." B."Have you asked your partner about their feelings?" C."We can work on that after you are feeling stronger." D."It sounds like you are concerned about how your body looks after surgery."

ANS: D The nurse should allow the client to continue expressing feelings by verbalizing the implied meaning of the client's statement. Other statements either minimize the client's feelings or discourage ongoing expression of emotion that is often associated with breast cancer and surgical intervention.

The nurse is caring for a client who has had a transurethral resection of the prostate (TURP). Which assessment finding requires immediate nursing intervention? A.Temperature 99.9 ℉ B.Pain of 6 on 0-10 scale C.Report of bladder spasms D. Bleeding from the surgical site

ANS: D The patient may be at risk for pain, infection, and bladder spasms after a TURP, but the highest risk of concern is for hemorrhage. After a TURP, assess for postoperative bleeding. Patients who undergo a TURP or open prostatectomy are at risk for severe bleeding or hemorrhage after surgery. Although rare, bleeding is most likely to occur within the first 24 hours. Blood transfusions are commonly given after a TURP surgery, but not needed after the HoLEP procedure. Bladder spasms or movement may trigger fresh bleeding from previously controlled vessels. This bleeding may be arterial or venous, but venous bleeding is more common

NCLEX Examination Challenge 66.3 Psychosocial Integrity The nurse is preparing a client for surgery related to ovarian cancer. When the client states, "I'm just going to die anyway; why do I even need this surgery?" what is the appropriate nursing response? A. "We don't know that you will die from this." B. "Are you thinking of canceling the surgery?" C. "Ovarian cancer has an unfavorable prognosis." D. "If the condition is fatal, hospice can provide care."

B. "Are you thinking of canceling the surgery?"

Ch 67 1. The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. "I can have sex up to 8 hours after taking the drug." B. "I might get a headache or stuffy nose when this drug is used." C. "Taking this with a drink or two of alcohol will enhance my performance." D. "If one pill doesn't work, it is acceptable for me to quickly take another pill."

B. "I might get a headache or stuffy nose when this drug is used."

2. The nurse has provided teaching to a client with vulvovaginitis. Which client statement indicates that nursing intervention is required? Select all that apply. A. "I will wipe from the front to the back." B. "I will wash with fragranced soap to prevent odor." C. "I am going to the store now to buy cotton underwear." D. "I will use fragrance-free laundry detergents in the future." E. "I am going to take all of the medicine the provider prescribed."

B. "I will wash with fragranced soap to prevent odor."

Ch 67 2. A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. "Taking ibuprofen may help alleviate the pain." B. "Please go to your closest emergency department right away." C. "This is a common reaction when performing labor; the pain will go away." D. "Your BPH is probably giving you difficulty because you were moving furniture."

B. "Please go to your closest emergency department right away."

1. What teaching will the nurse provide to a 30-year-old female client who has never been sexually active about decreasing her risk of developing cervical cancer? Select all that apply. A. "You cannot lower the risk for cervical cancer." B. "You cannot receive the Gardasil-9 immunization." C. "Use condoms when you plan to be sexually intimate." D. "Over-the-counter contraceptive methods can be used to prevent HPV." E. "Having an annual Pap test will decrease your chances of cervical cancer."

B. "You cannot receive the Gardasil-9 immunization." C. "Use condoms when you plan to be sexually intimate."

Ch 69 2. The nurse is caring for a 33-year-old female client who has been intimate with women and men. What teaching will the nurse provide regarding the Gardisil 9 vaccine? A. "Patients older than 26 cannot receive an HPV vaccine." B. "You will need three doses of the vaccine instead of two." C. "I will give you a single dose and you will be protected from future HPV." D. "HPV vaccines must be administered to people who have never had intercourse."

B. "You will need three doses of the vaccine instead of two."

NCLEX Examination Challenge 65.1 Health Promotion and Maintenance When caring for four clients, which individual does the nurse identify as being at the highest risk for development of breast cancer? A. 33-year-old male with gynecomastia and obesity B. 45-year-old female whose mother has breast cancer C. 60-year-old male whose father died from colon cancer D. 72-year-old female who was treated for breast cancer 3 years ago

B. 45-year-old female whose mother has breast cancer

NCLEX Examination Challenge 68.2 Physiological Integrity The nurse is caring for a client who had a vaginoplasty yesterday. Which assessment finding will the nurse report to the health care provider? A. Perineal pain B. Lower extremity swelling C. Constipation D. Urinary retention

B. Lower extremity swelling

NCLEX Examination Challenge 66.1 Physiological Integrity The nurse is caring for a client who just had a laparoscopic total abdominal hysterectomy. Which assessment finding requires immediate nursing intervention? A. Temperature of 99.2°F (37.3°C) B. One saturated perineal pad per hour C. Decreased bowel sounds in all quadrants D. Report of pain level of 5 on a scale of 0 to 10

B. One saturated perineal pad per hour

CH 65 1. Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? Select all that apply. A. Encourage client to accept her new body image. B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastectomy. E. Involve partner in discussions about sexuality if client desires.

B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastectomy. E. Involve partner in discussions about sexuality if client desires.

CH 65 2. Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the health care provider? A. Temperature of 99°F B. Tingling sensation in the right arm C. Impaired range of motion in the right arm D. Drainage of 20 mL collected over 24 hours

B. Tingling sensation in the right arm

NCLEX Examination Challenge 69.1 Physiological Integrity The nurse is caring for a client who has just been diagnosed with primary syphilis. Which client statement reflects that teaching has been effective? Select all that apply. A. "I can resume having intercourse right after this injection." B. "At least this infection is not as serious as gonorrhea or chlamydia." C. "I'm afraid, but I'm going to tell my partners about my diagnosis." D. "After my treatment, I still need several follow-up appointments." E. "I can take acetaminophen if I get a fever and chills after this shot." F. "I am going to wait here in the clinic 30 minutes after treatment."

C. "I'm afraid, but I'm going to tell my partners about my diagnosis." D. "After my treatment, I still need several follow-up appointments." E. "I can take acetaminophen if I get a fever and chills after this shot." F. "I am going to wait here in the clinic 30 minutes after treatment."

NCLEX Examination Challenge 64.1 Health Promotion and Maintenance A 68-year-old client who has had normal Pap results for 10 years and no history of cancer asks about scheduling a Pap smear. Which nursing response is appropriate? A. "You will need a Pap test this year." B. "You aren't due for a Pap test until next year." C. "You do not need to have further Pap tests at this time." D. "You do not need a Pap test unless you are sexually active."

C. "You do not need to have further Pap tests at this time." Women older than 65 years who have had regular cervical cancer testing with normal results in the past decade, and no serious cancers in the past 20 years, do not need further Pap testing.

NCLEX Examination Challenge 67.2 Physiological Integrity The nurse notes bright red urinary drainage from a client who had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. What is the appropriate initial nursing action? A. Calculate intake and output. B. Monitor hemoglobin and hematocrit. C. Increase the rate of the bladder irrigation. D. Document findings in the electronic health record.

C. Increase the rate of the bladder irrigation.

NCLEX Examination Challenge 64.2 Physiological Integrity A client has been scheduled for a transvaginal ultrasound. Which allergy does the nurse identify that should be immediately reported to the health care provider? A. Eggs B. Corn C. Latex D. Iodine

C. Latex

CH 68 2. Which nursing action decreases the risk for health care disparities for transgender clients? Select all that apply. A. Refer to the client's identification card for name. B. Determine gender identity based on clothing worn. C. Seek to understand the experience of the transgender client. D. Apologize several times if the wrong name is used for the client. E. On meeting the client, ask what name and which pronouns are desired. F. Explain how the health history and assessment are affected by gender identity.

C. Seek to understand the experience of the transgender client. E. On meeting the client, ask what name and which pronouns are desired. F. Explain how the health history and assessment are affected by gender identity.

NCLEX Examination Challenge 68.1 Physiological Integrity The nurse provides health teaching for a transgender woman receiving estrogen therapy. Which statement by the client indicates a need for further teaching? A. "I'll call my doctor if I have any redness or swelling in my legs." B. "I'll have less hair on my body after taking this drug." C. "I know that the drug will make my breasts bigger." D. "I think I will have more sex drive when taking this drug."

D. "I think I will have more sex drive when taking this drug."

1. A client has undergone a prostate biopsy. Which postprocedure symptom will the nurse teach the client to report immediately to the primary health care provider? A. Semen discoloration 5 days after biopsy B. Light rectal bleeding 2 days after procedure C. Tenderness at the site 1 day after biopsy D. Pain on urination 3 days after procedure

D. Pain on urination 3 days after procedure

NCLEX Examination Challenge 67.3 Physiological Integrity Which assessment finding will the nurse report to the health care provider for a client who had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning? A. BP 130/80 mm Hg, T 98.9°F, R 16, P 70 B. Urinary catheter draining clear yellow urine C. Expresses fearfulness of inability to perform sexually D. Reports pain of 9 on a 0-10 scale after receiving pain medication

D. Reports pain of 9 on a 0-10 scale after receiving pain medication

The health care provider orders a prostate ultrasound; the client is soon diagnosed with BPH, and prescribed finasteride. What teaching will the nurse provide?

Finasteride is a 5-alpha reductase inhibitor (5-ARI) that lowers DHT and shrinks the prostate as well as prevents further growth. It is important to remind clients taking a 5-ARI drug that it may take up to 6 months before improvement occurs. Side effects include erectile dysfunction and decreased libido.

When assessing the patient with benign prostatic hyperplasia (BPH). Which assessment finding does the nurse anticipate?

In a patient with BPH, a distended bladder is anticipated.

Six months later, the client's symptoms have not significantly improved. After consulting with a surgeon, he is scheduled for a transurethral resection of the prostate (TURP). Which postoperative interventions will the nurse provide?

The client should be helped out of bed to the chair as soon as permitted to prevent complication of immobility. The nurse will assess for signs of infection, check urinary output every 2 hours, remind the client that urine may be blood-tinged, and administer pain and antispasmodic medications as needed.