LACHARITY 17- Reproductive Problems

Question 1

A client who is being treated as an outpatient for pelvic inflammatory disease
(PID) with oral antibiotics returns to the clinic after 3 days of treatment.
Which finding by the nurse is of highest concern?
1. Client reports nausea after taking the antibiotics.
2. Client’s abdominal rebound pain is unchanged.
3. Client says she feels ashamed to have the infection.
4. Client’s cervical culture report shows gonorrhea.

Answer 1

Ans: 2 Because clinical manifestations of PID should be improving with 3
days of effective antibiotic treatment, the client’s ongoing pain indicates a
need for actions such as hospitalization for intravenous antibiotic therapy.
Nausea is an adverse effect of many antibiotics, but the client will be
instructed to continue the medications. The client’s feeling of shame should
be addressed by the nurse but is not the most important finding. Because
Neisseria gonorrhoeae is a common cause of PID, all drug regimens that are
used will be effective in treating gonorrhea (and Chlamydia trachomatis).
Focus: Prioritization.

Question 2

The nurse obtains the health history of a 37-year-old woman who is
requesting contraceptive therapy. Which information about the client will
have the most impact on the choice of contraceptive?
1. History of uterine fibroids
2. Blood pressure of 136/80 mm Hg
3. Cigarette smoking of a pack/day
4. Planning outpatient oral surgery

Answer 2

Ans: 3 The most commonly prescribed oral contraceptives are combination
estrogen-progestin medications, but estrogen-containing oral contraceptives
are contraindicated for women who are older than 35 years and who smoke
because of the increased risk for thromboembolism. A progestin-only oral
contraceptive or an intrauterine device (IUD) may be prescribed for this
client. Estrogen-containing contraceptives may stimulate fibroid growth and
elevate blood pressure, but these are relative contraindications. It is
recommended that estrogen-containing contraceptives be discontinued a few
weeks before surgeries that might impair mobility and increase venous
thromboembolism risk, but oral surgery will not affect mobility. Focus:
Prioritization.

Question 3

A postmenopausal woman who is taking raloxifene for osteoporosis calls the
clinic nurse with these concerns. Which information indicates a need for
immediate further evaluation?
1. Experiences hot flashes several times weekly
2. Describes family history of coronary artery disease
3. Reports nasal stuffiness and runny nose
4. Notices swelling and tenderness in left calf

Answer 3

Ans: 4 Raloxifene increases the risk for deep vein thrombosis and pulmonary
embolism, and the client should be evaluated further with an examination,
possible venous ultrasonography, and coagulation studies. Hot flashes and
nasal congestion are common side effects of raloxifene but are not reasons to
discontinue the medication. Raloxifene lowers myocardial infarction risk in
women at high risk. Focus: Prioritization.

Question 4

The nurse is assessing a long-term-care client with a history of benign
prostatic hyperplasia. Which information will require the most immediate
action?
1. The client states that he always has trouble starting his urinary stream.
2. The chart shows an elevated level of prostate-specific antigen.
3. The bladder is palpable above the symphysis pubis, and the client is
restless.
4. The client says he has not voided since having a glass of juice 4 hours ago.

Answer 4

Ans: 3 A palpable bladder and restlessness are indicators of urinary retention,
which would require action (e.g., insertion of a catheter) to empty the
bladder. The other data would be consistent with the client’s diagnosis of
benign prostatic hyperplasia. More detailed assessment may be indicated, but
no immediate action is required. Focus: Prioritization.

Question 5

While performing a breast examination on a 22-year-old client, the nurse
obtains these data. Which finding is of most concern?
1. Both breasts have many nodules in the upper outer quadrants.
2. The client reports bilateral breast tenderness with palpation.
3. The breast on the right side is slightly larger than the left breast.
4. An irregularly shaped, nontender lump is palpable in the left breast.

Answer 5

Ans: 4 Irregularly shaped and nontender lumps are consistent with a
diagnosis of breast cancer, so this client needs immediate referral for
diagnostic tests such as mammography or ultrasonography. The other
information is not unusual and does not indicate the need for immediate
action. Focus: Prioritization; Test Taking Tip: Remember to investigate
further when a client has a nontender lump or swelling because lumps that
are not painful are a common clinical manifestation of cancer in areas such as
the breasts or lymph tissues. Pain is rarely an early manifestation of cancer
but occurs as tumors grow and place pressure on other organs or tissues.

Question 6

After undergoing a modified radical mastectomy, a client is transferred to the
317postanesthesia care unit. Which nursing action is best to assign to an
experienced LPN/LVN?
1. Monitoring the client’s dressing for any signs of bleeding
2. Documenting the initial assessment on the client’s chart
3. Communicating the client’s status report to the charge nurse on the surgical
unit
4. Teaching the client about the importance of using pain medication as
needed

Answer 6

Ans: 1 An LPN/LVN working in a postanesthesia care unit would be
expected to check dressings for bleeding and alert RN staff members if
bleeding occurs. The other tasks are more appropriate for nursing staff with
RN-level education and licensure. Focus: Assignment.

Question 7

The nurse is working with an unlicensed assistive personnel (UAP) to care for
a client who has had a right breast lumpectomy and axillary lymph node
dissection. Which nursing action can be delegated to the UAP?
1. Teaching the client why blood pressure measurements are taken on the left
arm
2. Elevating the client’s arm on two pillows to promote lymphatic drainage
3. Assessing the client’s right arm for lymphedema
4. Reinforcing the dressing if it becomes saturated

Answer 7

Ans: 2 Positioning the client’s arm is a task within the scope of practice for
UAP working on a surgical unit. Client teaching and assessment are RN-level
skills. The RN should reinforce dressings as necessary because this requires
assessment of the surgical site and possible communication with the surgeon.
Focus: Delegation.

Question 8

The nurse obtains the following assessment data about a client who has had a
transurethral resection of the prostate (TURP) and has continuous bladder
irrigation. Which finding indicates the most immediate need for nursing
intervention?
1. The client states that he feels a continuous urge to void.
2. The catheter drainage is light pink with occasional clots.
3. The catheter is taped to the client’s thigh.
4. The client reports painful bladder spasms.

Answer 8

Ans: 4 The bladder spasms may indicate that blood clots are obstructing the
catheter, which would indicate the need for irrigation of the catheter with 30
to 50 mL of normal saline using a piston syringe. The other data would all be
normal after a TURP, but the client may need some teaching about the usual
post-TURP symptoms and care. Focus: Prioritization.

Question 9

A client with benign prostatic hyperplasia has a new prescription for
tamsulosin. Which statement about tamsulosin is most important to include
when teaching this client?
1. “This medication will improve your symptoms by shrinking the prostate.”
2. “The force of your urinary stream will probably increase.”
3. “Your blood pressure might decrease as a result of taking this medication.”
4. “You should avoid sitting up or standing up too quickly.”

Answer 9

Ans: 4 Because tamsulosin blocks alpha receptors in the peripheral arterial
system, the most significant side effects are orthostatic hypotension and
dizziness. To avoid falls, it is important that the client change positions
slowly. The other information is also accurate and may be included in client
teaching but is not as important as decreasing the risk for falls. Focus:
Prioritization; Test Taking Tip: When any medication might lower blood
pressure, be aware that safety is a priority. Avoid risk for falls by teaching
clients to change position slowly.

Question 10

The nurse is caring for a client who has just returned to the surgical unit
after a transurethral resection of the prostate (TURP). Which assessment
finding will require the most immediate action?
1. Blood pressure reading of 153/88 mm Hg
2. Catheter that is draining deep red blood
3. Client not wearing antiembolism hose
4. Client report of abdominal cramping

Answer 10

Ans: 2 Hemorrhage is a major complication after TURP and should be
reported to the surgeon immediately. The other assessment data also indicate
a need for nursing action but not as urgently. Focus: Prioritization.

Question 11

After a radical prostatectomy, a client is ready to be discharged. Which
nursing action included in the discharge plan should be assigned to an
318experienced LPN/LVN?
1. Reinforcing the client’s need to check his temperature daily
2. Teaching the client how to care for his retention catheter
3. Documenting a discharge assessment in the client’s chart
4. Instructing the client about the prescribed narcotic analgesic

Answer 11

Ans: 1 Reinforcement of previous teaching is an expected role of the
LPN/LVN. Planning and implementing client initial teaching and
documentation of a client’s discharge assessment should be performed by
experienced RN staff members. Focus: Assignment.

Question 12

The day after a radical prostatectomy, a client has blood clots in the urinary
catheter and reports bladder spasms. The client says that his right calf is sore
and that he feels short of breath. Which action will the nurse take first?
1. Irrigate the catheter with 50 mL of sterile saline.
2. Administer oxybutynin 5 mg orally.
3. Apply warm packs to the right calf.
4. Measure oxygen saturation using pulse oximetry.

Answer 12

Ans: 4 It is important to assess oxygenation because the client’s calf
tenderness and shortness of breath suggest a possible venous
thromboembolism and pulmonary embolus, serious complications of
transurethral resection of the prostate. The other activities are appropriate but
are not as high a priority as ensuring that oxygenation is adequate. Focus:
Prioritization; Test Taking Tip: You should rapidly investigate any client
report of shortness of breath because oxygenation is the most basic
physiologic need.

Question 13

The emergency department nurse receives change-of-shift report about four
clients. Which one should be assessed first?
1. A 19-year-old client with scrotal swelling and severe pain that has not
decreased with elevation of the scrotum
2. A 25-year-old client who has a painless indurated lesion on the glans penis
3. A 44-year-old client with an elevated temperature, chills, and back pain
associated with recurrent prostatitis
4. A 77-year-old client with abdominal pain and acute bladder distention

Answer 13

Ans: 1 This client has symptoms of testicular torsion, an emergency that
needs immediate assessment and intervention because it can lead to testicular
ischemia and necrosis within a few hours. The other clients also have
symptoms of acute problems (primary syphilis, acute bacterial prostatitis,
and prostatic hyperplasia with urinary retention), which need rapid
assessment and intervention, but these are not as urgent as the possible
326testicular torsion. Focus: Prioritization

Question 14

The nurse obtains this information when taking the health history of a 56-
year-old postmenopausal woman. Which information is most important to
report to the health care provider (HCP)?
1. Sagging of breasts bilaterally
2. Vaginal dryness and painful intercourse
3. Hot flashes occurring during the night
4. Occasional painless vaginal bleeding

Answer 14

Ans: 4 Painless vaginal bleeding in postmenopausal women may indicate
endometrial or cervical cancer and will require diagnostic testing such as
endometrial biopsy. Breast atrophy, vaginal dryness and painful intercourse,
and hot flashes are common after menopause, although these symptoms
should also be discussed with the HCP and may need treatment. Focus:
Prioritization.

Question 15

The nurse is interviewing a woman who is in the clinic for a well woman
exam, and the woman requests a screening test for ovarian cancer. Which
response by the nurse is best?
1. “Only a small number of ovarian cancers are diagnosed at an early stage.”
2. “There is no effective screening test for ovarian cancer in low-risk women.”
3. “Benefits of ovarian cancer screening will depend on your medical history.”
4. “Ovarian cancer screening will probably not be covered by your
insurance.”

Answer 15

Ans: 3 Current guidelines state that there is no effective screening tool for
low-risk women, but women who are high risk because of family history or
the BRCA genes may be screened with transvaginal ultrasonography and
serum marker CA-125 levels. The other statements are accurate but do not
respond as well to the client’s concern. Focus: Prioritization.

Question 16

A client who has just returned to the surgical unit after a transurethral
resection of the prostate (TURP) reports acute bladder spasms. In which
order will the nurse perform these prescribed actions?
1. Administer acetaminophen/oxycodone 325 mg/5 mg.
3192. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline.
3. Infuse 500 mL of 5% dextrose in lactated Ringer’s solution over 2 hours.
4. Offer the client oral fluids to at least 2500 to 3000 mL/day.

Answer 16

Ans: 2, 1, 3, 4 Bladder spasms after a TURP are usually caused by the
presence of clots that obstruct the catheter, so irrigation should be the first
action taken. Administration of analgesics may help to reduce spasm.
Administration of a bolus of IV fluids is commonly used in the immediate
postoperative period to help maintain fluid intake and increase urinary flow.
Oral fluid intake should be encouraged when the nurse is sure that the client
is not nauseated and has adequate bowel tone. Focus: Prioritization.

Question 17

A 68-year-old client who is ready for discharge from the emergency
department has a new prescription for nitroglycerin 0.4 mg sublingual as
needed for angina. Which client information has the most immediate
implications for teaching?
1. The client has prostatic hyperplasia with some urinary hesitancy.
2. The client’s father and two brothers all have had myocardial infarctions.
3. The client uses sildenafil several times weekly for erectile dysfunction.
4. The client is unable to remember when he first experienced chest pain.

Answer 17

Ans: 3 Sildenafil is a potent vasodilator and has caused cardiac arrest in
clients who were also taking nitrates such as nitroglycerin. The other client
data indicate the need for further assessment or teaching, but it is essential for
the client who uses nitrates to avoid concurrent use of sildenafil. Focus:
Prioritization.

Question 18

The nurse is caring for a 21-year-old client who had a left orchiectomy for
testicular cancer on the previous day. Which nursing activity will be best to
assign to an LPN/LVN?
1. Educating the client about post-orchiectomy chemotherapy and radiation
2. Administering the prescribed “as needed” (PRN) oxycodone to the client
3. Teaching the client how to do testicular self-examination on the remaining
testicle
4. Assessing the client’s knowledge level about post-orchiectomy fertility

Answer 18

Ans: 2 Administration of narcotics and the associated client monitoring are
included in LPN/LVN education and scope of practice. Assessments and
teaching are more complex skills that require RN-level education and are best
accomplished by an RN with experience in caring for clients with this
diagnosis. Focus: Assignment.

Question 19

Which client is best for the oncology unit charge nurse to assign to an RN
who has floated from the emergency department?
1. Client who needs doxorubicin chemotherapy to treat metastatic breast
cancer
2. Client who needs discharge teaching after surgery for stage II ovarian
cancer
3. Client with metastatic prostate cancer who requires frequent assessment
and treatment for breakthrough pain
4. Client with testicular cancer who requires preoperative teaching about
orchiectomy and lymph node resection

Answer 19

Ans: 3 An RN from the emergency department would be experienced in
assessment and management of pain. Because of their diagnoses and
treatments, the other clients should be assigned to RNs who are experienced
in caring for clients with cancer. Focus: Assignment; Test Taking Tip: When
making assignments for nurses who have floated to a specialty area, it is best
to assign the float nurse to clients who require actions that are commonly
used in many areas of nursing, such as administration of analgesics, dressing
changes, and fluid infusions.

Question 20

After receiving the change-of-shift report, in which order will the nurse
assess these assigned clients?
1. A 22-year-old client who has questions about how to care for the drains
placed in her breast reconstruction incision
2. An anxious 44-year-old client who is scheduled to be discharged today
after undergoing a total vaginal hysterectomy
3. A 69-year-old client who reports level 5 pain (on a scale of 0 to 10) after
undergoing perineal prostatectomy 2 days ago
4. A usually oriented 78-year-old client who has new-onset confusion after
having a bilateral orchiectomy the previous day

Answer 20

Ans: 4, 3, 2, 1 The bilateral orchiectomy client needs immediate assessment
because confusion may be an indicator of serious postoperative complications
such as hemorrhage, infection, or pulmonary embolism. The client who had a
perineal prostatectomy should be assessed next because pain medication may
be needed to allow him to perform essential postoperative activities such as
deep breathing, coughing, and ambulating. The vaginal hysterectomy client’s
327anxiety needs further assessment next. Although the breast implant client has
questions about care of the drains at the surgical site, there is nothing in the
report indicating that these need to be addressed immediately. Focus:
Prioritization.

Question 21

A client has had a needle biopsy of the prostate gland using the transrectal
approach. Which statement is most important to include in the client teaching
plan?
1. “The health care provider (HCP) will call you about the test results.”
2. “Serious infections may occur as a complication of this test.”
3. “You will need to call the HCP if you develop a fever or chills.”
4. “It is normal to have a small amount of rectal bleeding after the test.”

Answer 21

Ans: 3 Although infection occurs only rarely as a complication of transrectal
prostate biopsy, it is important that the client receive teaching about checking
his temperature and calling the HCP if there is any fever or other signs of
systemic infection. The client should understand that the test results will not
be available immediately but that he will be notified about the results.
Transient rectal bleeding may occur after the biopsy, but bleeding that lasts
for more than a few hours indicates that there may have been rectal trauma.
Focus: Prioritization.

Question 22

The nurse is working in the postanesthesia care unit caring for a 32-year-old
client who has just arrived after undergoing dilation and curettage to
evaluate infertility. Which assessment finding should be immediately
communicated to the surgeon?
1. Blood pressure of 162/90 mm Hg
2. Saturation of the perineal pad after the first 30 minutes
3. Oxygen saturation of 91% to 95%
4. Sharp, continuous, level 8 abdominal pain (on a scale of 0 to 10)

Answer 22

Ans: 4 Cramping or aching abdominal pain is common after dilation and
curettage; however, sharp, continuous pain may indicate uterine perforation,
which would require rapid intervention by the surgeon. The other data
indicate a need for ongoing assessment or interventions. Transient blood
pressure elevation may occur because of the stress response after surgery.
Bleeding after the procedure is expected but should decrease over the first 2
hours. Although the oxygen saturation is not at an unsafe level, interventions
to improve the saturation should be carried out. Focus: Prioritization.

Question 23

When the nurse is developing the plan of care for a home health client who
has been discharged after a radical prostatectomy, which activities will be
delegated to the home health aide? Select all that apply.
1. Monitoring the client for symptoms of urinary tract infection
2. Helping the client to connect the catheter to the leg bag
3. Checking the client’s incision for appropriate wound healing
4. Assisting the client in ambulating for increasing distances
5. Helping the client shower at least every other day

Answer 23

Ans: 2, 4, 5 Assisting with catheter care, ambulation, and hygiene are
included in home health aide education and would be expected activities for
this staff member. Client assessments are the responsibility of RN members of
the home health care team. Focus: Delegation.

Question 24

The nurse is working in the emergency department when a client with
possible toxic shock syndrome is admitted. Which prescribed intervention
will the nurse implement first?
1. Remove the client’s tampon.
2. Obtain blood specimens for culture.
3. Give acetaminophen 650 mg.
4. Infuse nafcillin 1000 mg IV.

Answer 24

Ans: 1 Because the most likely source of the bacteria causing the toxic shock
syndrome is the client’s tampon, it is essential to remove it first. The other
actions should be implemented in the following order: obtain blood culture
samples (best done before initiating antibiotic therapy to ensure accurate
culture and sensitivity results), infuse nafcillin (rapid initiation of antibiotic
therapy will decrease bacterial release of toxins), and administer
acetaminophen (fever reduction may be necessary, but treating the infection
has the highest priority). Focus: Prioritization.

Question 25

Which information will the nurse include when teaching a group of 20-year-
old women about emergency contraception with levonorgestrel (the
morning-after pill)? Select all that apply.
1. Heavier menstrual bleeding is a common side effect of this medication
regimen.
2. Emergency contraception requires a prescription from a licensed health
care provider.
3. Even if pregnancy occurs after using emergency contraception, risk for
complications is low.
3214. Because nausea and vomiting may occur, an antiemetic may be used before
levonorgestrel.
5. The medication must be taken within the first 24 hours after unprotected
intercourse to be effective.

Answer 25

Ans: 1, 3, 4 Emergency contraception with levonorgestrel (Plan B) may cause
heavy menstrual bleeding and nausea with vomiting. Risk for pregnancy
complications is not increased. The medication is most effective if taken
within 72 hours, but it can be used up to 5 days after unprotected intercourse.
Levonorgestrel does not need a prescription when used for emergency
contraception by clients age 17 years or older. Focus: Prioritization.

Question 26

The clinic nurse reviews information about four clients who are requesting
Pap testing. Which client needs to be scheduled first?
1. A 19-year-old client who first had intercourse at age 13 years
2. A 25-year-old client who has never had a pelvic examination
3. A 33-year-old client who had a normal Pap test 2 years previously
4. A 67-year-old client who says her previous Pap test results have been
normal

Answer 26

Ans: 2 Current guidelines indicate that Pap testing should be started at age
21 years, regardless of when a woman has become sexually active. The 19-
year-old client should be counseled that there is an increased risk for cervical
cancer associated with sexual activity before age 17 years and encouraged to
schedule Pap testing, human papillomavirus testing, or both at age 21 years.
328The 33-year-old client will need screening every 3 years, and the 67-year-old
will not need further Pap screening if she has had several normal Pap test
results within the past 2 to 3 years. Focus: Prioritization.

Question 27

When assessing a client with cervical cancer who had a total abdominal
hysterectomy yesterday, the nurse obtains the following data. Which
information has the most immediate implications for planning of the client’s
care?
1. Fine crackles are audible at the lung bases.
2. The client’s right calf is swollen, and she reports mild calf tenderness.
3. The client uses the patient-controlled analgesia device every 30 minutes.
4. Urine in the collection bag is amber and clear.

Answer 27

Ans: 2 Right calf swelling and tenderness indicate the possible presence of
deep vein thrombosis. This will change the plan of care because the client
may be placed on bed rest and will require diagnostic testing and possible
anticoagulant therapy. The other data indicate the need for common
postoperative nursing actions such as having the client cough, assessing her
pain, and increasing her fluid intake. Focus: Prioritization.

Question 28

The nurse is supervising a student nurse who is caring for a client who has
an intracavitary radioactive implant in place to treat cervical cancer. Which
action by the student requires that the nurse intervene immediately?
1. Standing next to the client for 5 minutes while assisting with her bath
2. Asking the client how she feels about losing her childbearing ability
3. Assisting the client to the bedside commode for a bowel movement
4. Offering to get the client whatever she would like to eat or drink

Answer 28

Ans: 3 Clients with intracavitary implants are kept in bed during the
treatment to avoid dislodgement of the implant. The other actions may also
require the nurse to intervene by providing guidance to the student. Minimal
time should be spent close to clients who are receiving internal irradiation.
Asking the client about her reaction to losing childbearing abilities may be
inappropriate at this time. Clients are frequently placed on low-residue diets
to decrease bowel distention while implants are in place. Focus:
Prioritization.

Question 29

A client who had an abdominal hysterectomy 3 days ago reports burning
with urination. Her urine output during the previous shift was 210 mL, and
her temperature is 101.3°F (38.5°C). Which of these actions prescribed by the
health care provider will the nurse implement first?
1. Insert a straight catheter as needed (PRN) for output of less than
300 mL/8 hr.
2. Administer acetaminophen 650 mg now and every 6 hours PRN.
3. Send a urine specimen to the laboratory for culture and sensitivity testing.
4. Administer ceftizoxime 1 g IV now and every 12 hours.

Answer 29

Ans: 1 The client has symptoms of a urinary tract infection. Inserting a
straight catheter will enable the nurse to obtain an uncontaminated urine
specimen for culture and sensitivity testing before the antibiotic is started. In
addition, the client is probably not emptying her bladder fully because of the
painful urination. The antibiotic therapy should be initiated as rapidly as
possible after the urine specimen is obtained. Administration of
acetaminophen is the lowest priority because the client’s temperature is not
dangerously elevated. Focus: Prioritization.

Question 30

An 86-year-old woman had an anterior and posterior colporrhaphy (A & P
repair) several days ago. Her retention catheter was removed 8 hours ago.
Which assessment finding requires that the nurse act most rapidly?
1. Her oral temperature is 100.7°F (38.2°C).
2. Her abdomen is firm and tender to palpation above the symphysis pubis.
3223. Her breath sounds are decreased, with fine crackles audible at both bases.
4. Her apical pulse is 86 beats/min and slightly irregular.

Answer 30

Ans: 2 After an A & P repair, it is essential that the bladder be empty to
avoid putting pressure on the suture lines. The abdominal firmness and
tenderness indicate that the client’s bladder is distended. The health care
provider should be notified and an order for catheterization obtained. The
other data also indicate a need for further assessment of her cardiac status
and actions such as having the client cough and deep breathe, but these are
not such immediate concerns. Focus: Prioritization.

Question 31

The nurse is reviewing medication lists for several clients. Which medication
is most important for the nurse to question?
1. Testosterone transdermal gel for a client who has prostate cancer
2. Metformin for a client whose only diagnosis is polycystic ovary syndrome
3. Sildenafil for a client who is also taking hydrochlorothiazide for
hypertension
4. Methoprogesterone for a client who has infertility associated with
endometriosis

Answer 31

Ans: 1 Testosterone is contraindicated in clients who have prostate cancer
because it can promote growth of prostate cancer. Although metformin is
most commonly prescribed for type 2 diabetes, it can be helpful in restoring
ovulation in clients with polycystic ovary syndrome. Sildenafil lowers blood
pressure and should not be used by clients who are taking nitrates or alpha-
adrenergic blockers but may be used in clients taking other
antihypertensives. Progestin therapy alone will not treat infertility caused by
endometriosis but may be used to shrink endometrial tissue. Focus:
Prioritization.

Question 32

The nurse is providing orientation for a new RN on the medical-surgical unit
who is caring for a client with severe pelvic inflammatory disease (PID).
Which action by the new RN is most important to correct quickly?
1. Telling the client that she should avoid using tampons in the future
2. Offering the client an ice pack to decrease her abdominal pain
3. Positioning the client flat in bed while helping her take a bath
4. Teaching the client that she should not have intercourse for 2 months

Answer 32

Ans: 3 The client should be positioned in a semi-Fowler position to decrease
pain and minimize the risk of abscess development higher in the abdomen.
329The other actions also require correction but not as rapidly. Tampon use is
not contraindicated after an episode of PID, although some sources
recommend not using tampons during the acute infection. Heat application
to the abdomen and pelvis is used for pain relief. Intercourse is safe a few
weeks after effective treatment for PID. Focus: Prioritization.

Question 33

Which information obtained when taking a client’s health history will be
most important in determining whether the client should receive the human
papillomavirus (HPV) immunization?
1. Client is 19 years old.
2. Client is sexually active.
3. Client has a positive pregnancy test result.
4. Client has tested positive for HPV previously.

Answer 33

Ans: 3 Centers for Disease Control and Prevention guidelines indicate that
the HPV immunization should not be given during pregnancy. Ideally, the
immunization series should start at age 11 or 12 years for girls and boys, but
it may be started up through age 26 years. HPV immunization is most
effective in preventing HPV infection and cervical cancer when it is started
before the individual is sexually active and before any HPV infection, but
these are not contraindications for vaccination. Focus: Prioritization.

Question 34

Three days after undergoing a pelvic exenteration procedure, a client reports
dizziness after experiencing a sudden “giving” sensation along her
abdominal incision. The nurse finds that the wound edges are open, and
loops of intestine are protruding. Which action should the nurse take first?
1. Notify the surgeon that wound evisceration has occurred.
2. Cover the wound with saline-soaked dressings.
3. Use swabs to obtain aerobic and anaerobic wound cultures.
4. Call for assistance from the Rapid Response Team (RRT).

Answer 34

Ans: 2 The initial action should be to ensure that the abdominal contents
remain moist by covering the wound and loops of intestine with dressings
soaked with sterile normal saline. Because national guidelines addressing the
use of RRTs indicate that the role of the RRT is immediate assessment and
stabilization of the client, the nurse’s next action should be to activate the
RRT. The surgeon should be notified after further assessments of the client
(e.g., pulse and blood pressure) are obtained. Wound cultures may be
obtained, but protection of the wound, further assessment of the client, and
then notification of the surgeon so that other actions can be taken are the
priority. Focus: Prioritization.

Question 35

The nurse is working on a medical unit staffed with LPNs/LVNs and
unlicensed assistive personnel (UAP) when a client with stage IV ovarian
cancer and recurrent ascites is admitted for paracentesis. Which activity is
best to assign to an experienced LPN/LVN?
1. Obtaining a paracentesis tray from the central supply area
2. Completing the short-stay client admission form
3. Measuring vital signs every 15 minutes after the procedure
3234. Providing discharge instructions after the procedure

Answer 35

Ans: 3 LPN/LVN education includes vital sign monitoring after procedures
such as paracentesis; an experienced LPN/LVN would recognize and report
significant changes in vital signs to the RN. The paracentesis tray could be
obtained by a UAP. Client admission assessment and teaching require RN-
level education and experience, although part of the data gathering may be
done by an LPN/LVN. Focus: Assignment.

Question 36

A new nurse who is assigned to care for a transgender client who has been
admitted with pneumonia tells the charge nurse, “I do not feel comfortable
caring for this client.” Which action should the charge nurse take first?
1. Teach the new nurse that culturally sensitive care for all clients is an
expectation for staff members.
2. Change the new nurse’s assignment for the day and arrange for more
training about transgender health.
3. Ask the new nurse to clarify the specific concerns about providing
treatment for a transgender client.
4. Explain to the new nurse that the treatment for pneumonia will not be
affected by the client’s transgender status.

Answer 36

Ans: 3 The initial response by the charge nurse should be assessment of the
new nurse’s concerns about caring for this client. Acknowledging the new
nurse’s concerns will be more effective than mandating culturally sensitive
care. Changing the assignment and arranging training may be appropriate,
but more information about the new nurse’s anxieties is needed first.
Treatment for pneumonia will not be different for a transgender client, but it
is important that the client’s care is provided in a nonjudgmental manner.
Focus: Prioritization.

Question 37

Which action by the nurse will best meet the goal of providing culturally
competent care for lesbian, gay, bisexual, and transgender clients?
1. Direct transgender clients to the unisex bathrooms.
2. Assure clients that they will all be treated the same way.
3. Ask all clients about sexual orientation and gender identification.
4. Develop forms that use gender-neutral terms to collect client information.

Answer 37

Ans: 4 The Joint Commission suggests that forms should use inclusive and
gender-neutral language to allow for client self-identification. Unisex or
single-stall bathrooms should be provided, but transgender clients should
also be able to use bathrooms consistent with their gender identity. Treating
all clients the same fails to acknowledge that sexual orientation and gender
identity may have an impact on health care needs. The nurse should be
receptive of information about client sexual orientation and gender identity,
but self-identification should be at the client’s chosen time. Focus:
330Prioritization.

Question 38

38. While the nurse is working in the clinic, a healthy 32-year-old woman whose
    sister is a carrier of the BRCA gene asks which form of breast cancer screening
    is the most effective for her. Which response is best?
39. “An annual mammogram is usually sufficient screening for women your
    age.”
40. “Monthly self-breast examination is recommended because of your higher
    risk.”
41. “A yearly breast examination by a health care provider should be
    scheduled.”
42. “Magnetic resonance imaging (MRI) is recommended in addition to annual
    mammography.”

Answer 38

Ans: 4 The current guidelines, supported by nonrandomized screening trials
and observational data, call for first-degree relatives of clients with the BRCA
gene to be screened with both annual mammography and MRI. Although
annual mammography, breast self-examination, and clinical breast
examination by a health care provider may help to detect cancer, the best
option for this client is annual mammography and MRI. Focus: Prioritization.

Question 39

A client with toxic shock syndrome is to receive clindamycin 900 mg IV over
60 minutes. The clindamycin is diluted in 100 mL of normal saline. The nurse
will infuse ____________________mL/hr.

Answer 39

Ans: 100 To infuse 100 mL over 60 minutes, the nurse will need to set the
infusion pump to give 100 mL/hr. Focus: Prioritization.