MS2 - Exam 4 - Reproductive Questions Flashcards Preview

Track 3 > MS2 - Exam 4 - Reproductive Questions > Flashcards

Flashcards in MS2 - Exam 4 - Reproductive Questions Deck (91):
0

When teaching a patient about ways to prevent primary dysmenorrhea, the nurse will suggest that the patient
a. avoid aerobic exercise during her menstrual period.
b. use cold packs on the abdomen and back for pain relief.
c. talk with her health care provider about antidepressant therapy.
d. start taking nonsteroidal antiinflammatory drugs (NSAIDs) regularly when her menstrual period starts.

ANS: D
NSAIDs should be started as soon as the menstrual period begins and taken at regular intervals during the usual time frame in which pain occurs. Aerobic exercise may help reduce symptoms. Heat therapy, such as warm packs, is recommended for relief of pain. Antidepressant therapy is not a typical treatment for dysmenorrhea.

1

A 33-year-old woman who uses oral contraceptives tells the nurse, "I want to have children in a few years." Which response by the nurse is appropriate?
a. "You may have more difficulty becoming pregnant after about age 35."
b. "You have many years of fertility left, so there is no rush to have children."
c. "You should plan to stop taking oral contraceptives several years before you want to become pregnant."
d. "If you do not have children within the next few years, it will be very difficult for you to become pregnant."

ANS: A
The probability of successfully becoming pregnant decreases after age 35, although some patients may have no difficulty in becoming pregnant. Oral contraceptives do not need to be withdrawn for several years for a woman to become pregnant. Although the patient may be fertile for many years, it would be inaccurate to indicate that there is no concern about infertility as she becomes older. Although the risk for infertility increases after age 35, not all patients have difficulty in conceiving.

2

A 46-year-old woman tells the nurse that she has not had a menstrual period for 3 months and asks whether she is going into menopause. The best response by the nurse is,
a. "Have you thought about using hormone replacement therapy?"
b. "Most women feel a little depressed about entering menopause."
c. "What was your menstrual pattern before your periods stopped?"
d. "Since you are in your mid-40s, it is likely that you are menopausal."

ANS: C
The initial response by the nurse should be to assess the patient's baseline menstrual pattern. Although many women do enter menopause in the mid-40s, more information about this patient is needed before telling her that it is likely she is menopausal. Although hormone replacement therapy (HRT) may be prescribed, further assessment of the patient is needed before discussing therapies for menopause. Because the response to menopause is very individual, the nurse should not assume that the patient is experiencing any adverse emotional reactions.

3

Which information will the nurse include when teaching a 51-year-old woman who is considering the use of combined estrogen-progesterone hormone replacement therapy (HRT) during menopause?
a. Use of estrogen-containing vaginal creams provides most of the same benefits as oral HRT.
b. Use of HRT for up to 10 years to prevent symptoms such as hot flashes is generally considered safe.
c. HRT decreases osteoporosis risk and increases the risk for cardiovascular disease and breast cancer.
d. Increased incidence of colon cancer in women taking HRT requires frequent stool assessment for occult blood.

ANS: C
Data from the Women's Health Initiative indicate an increased risk for cardiovascular disease and breast cancer in women taking combination HRT but a decrease in hip fractures. Vaginal creams decrease symptoms related to vaginal atrophy and dryness, but they do not offer the other benefits of HRT, such as decreased hot flashes. Most women who use HRT are placed on short-term treatment and are not treated for up to 10 years. The incidence of colon cancer decreases in women taking HRT.

4

When the nurse is caring for a patient with pelvic inflammatory disease (PID) requiring hospitalization, which nursing intervention will be included in the plan of care?
a. Monitor liver function tests.
b. Use cold packs PRN for pelvic pain.
c. Teach the patient how to perform Kegel exercises.
d. Elevate the head of the bed to at least 30 degrees.

ANS: D
The head of the bed should be elevated to at least 30 degrees to promote drainage of the pelvic cavity and prevent abscess formation higher in the abdomen. Although a possible complication of PID is acute perihepatitis, liver function tests will remain normal. There is no indication for increased fluid intake. Application of heat is used to reduce pain. Kegel exercises are not helpful in PID.

5

A patient with pelvic inflammatory disease (PID) is treated on an outpatient basis with oral antibiotics. Which instruction will be included in patient teaching?
a. Return for a follow-up appointment in 2 days.
b. Abdominal pain may persist for several weeks.
c. Sexual intercourse should be avoided for 1 week.
d. Nonsteroidal antiinflammatory drug (NSAID) use may prevent scarring of pelvic organs.

ANS: A
The patient is instructed to return for follow-up in 48 to 72 hours. The patient should abstain from intercourse for 3 weeks. Abdominal pain should subside with effective antibiotic therapy. Corticosteroids may help prevent inflammation and scarring, but NSAIDs will not decrease scarring.

6

A patient with endometriosis is treated with medroxyprogesterone (Depo-Provera). The nurse explains that this therapy
a. suppresses the menstrual cycle by mimicking pregnancy.
b. may cause symptoms such as vaginal atrophy and hot flashes.
c. is associated with loss of bone density and increased fracture risk.
d. will lead to permanent suppression of abnormal endometrial tissues.

ANS: A
Depo-Provera induces a pseudopregnancy, which suppresses ovulation and causes shrinkage of endometrial tissue. Vaginal atrophy and hot flashes are caused by synthetic androgens such as danazol or gonadotropin-releasing hormone agonists (GNRH) such as leuprolide. Although hormonal therapies will control endometriosis while the therapy is used, endometriosis will recur once the menstrual cycle is reestablished. Depo-Provera use is not associated with bone loss.

7

When caring for a patient recently diagnosed with polycystic ovary syndrome, it is most important for the nurse to teach the patient
a. reasons for a total hysterectomy.
b. how to decrease facial hair growth.
c. ways to reduce the occurrence of acne.
d. methods to maintain appropriate weight.

ANS: D
Obesity exacerbates the problems associated with polycystic ovary syndrome, such as insulin resistance and type 2 diabetes. The nurse also will address the problems of acne and hirsutism, but these symptoms are lower priority because they do not have long-term health consequences. Although some patients do require total hysterectomy, this is usually performed only after other therapies have been unsuccessful.

9

A patient with multiple uterine leiomyomas is admitted for an abdominal hysterectomy. Which topic will the nurse include in patient teaching?
a. Leg exercises and the purpose of frequent ambulation
b. Temporary decrease in vaginal sensation after surgery
c. Adverse effects of systemic chemotherapy or radiation
d. Symptoms caused by the sudden drop in estrogen level

ANS: A
Venous thromboembolism (VTE) is a potential complication after the surgery, and the nurse will instruct the patient about ways to prevent it. Vaginal sensation is decreased after a vaginal hysterectomy but not after abdominal hysterectomy. Leiomyomas are benign tumors, so chemotherapy and radiation will not be prescribed. Because the patient will still have her ovaries, the estrogen level will not decrease.

10

In telling a patient with infertility what she and her partner can expect, the nurse explains that
a. ovulatory studies can help determine tube patency.
b. a hysterosalpingogram is a common diagnostic study.
c. the cause will remain unexplained for 40% of couples.
d. if postcoital studies are normal, infection tests will be done.

b. a hysterosalpingogram is a common diagnostic study.

Rationale: Tubal factors (i.e., occlusion or deformity) are assessed most commonly by means of hysterosalpingography.

11

An appropriate question to ask the patient with painful menstruation to differentiate primary from secondary dysmenorrhea is
a. “Does your pain become worse with activity or overexertion?”
b. “Have you had a recent personal crisis or change in your lifestyle?”
c. “Is your pain relieved by nonsteroidal antiinflammatory medications?”
d. “When in your menstrual history did the pain with your period begin?”

d. “When in your menstrual history did the pain with your period begin?”

Rationale: Primary dysmenorrhea starts 12 to 24 hours before the onset of menses. The pain is most severe on the first day of menses and rarely lasts more than 2 days. Secondary dysmenorrhea usually occurs after the woman has experienced problem-free periods for some time. The pain may be unilateral, and it is usually more constant and continues longer than in primary dysmenorrhea. Depending on the cause, symptoms such as dyspareunia (pain during intercourse), pain during defecation, or irregular bleeding may occur at times other than menstruation.

12

The nurse should advise the woman recovering from surgical treatment of an ectopic pregnancy that
a. she has an increased risk for salpingitis.
b. bed rest must be maintained for 12 hours to assist in healing.
c. having one ectopic pregnancy increases her risk for another.
d. intrauterine devices and infertility treatments should be
avoided.

c. having one ectopic pregnancy increases her risk for another.

Rationale: Risk factors for ectopic pregnancy include a history of pelvic inflammatory disease, prior ectopic pregnancy, current use of a progestin-releasing intrauterine device (IUD), failure of progestin-only birth control, prior pelvic or tubal surgery, and procedures used in infertility treatment.

13

To prevent or decrease age-related changes that occur after menopause in a patient who chooses not to take hormone therapy, the most important self-care measure to teach is
a. maintaining usual sexual activity.
b. increasing the intake of dairy products.
c. performing regular aerobic, weight-bearing exercise.
d. taking vitamin E and B-complex vitamin supplements.

c. performing regular aerobic, weight-bearing exercise.

Rationale: A regular program (three to four times per week) of moderate aerobic and weight-bearing exercises can slow the process of bone loss and a tendency toward weight gain. Exercise is important for menopausal women in modifying risk factors for coronary artery disease, including stress, obesity, physical inactivity, and hypertension.

14

The patient’s thick, white, and curdlike vaginal discharge and vulvar pruritus are most consistent with
a. trichomoniasis.
b. monilial vaginitis.
c. bacterial vaginosis.
d. chlamydial cervicitis.

b. monilial vaginitis.

Rationale: Monilial vaginitis is a fungal infection. The clinical manifestations are pruritus and a thick, white, curdlike discharge.

15

In caring for a patient with pelvic inflammatory disease, the nurse should place her in semi-Fowler’s position. The rationale for this measure is to
a. relieve severe pain.
b. promote drainage to prevent abscesses.
c. improve circulation and promote healing.
d. prevent complication of bowel obstruction.

b. promote drainage to prevent abscesses.

Rationale: The nurse positions the patient with pelvic inflammatory disease in a semi-Fowler’s position. This position promotes drainage of the pelvic cavity by gravity and may prevent the development of abscesses high in the abdomen.

16

Postoperative goals in caring for the patient who has undergone an abdominal hysterectomy include (select all that apply)
a. monitoring urine output.
b. changing position frequently.
c. restricting all food for 24 hours.
d. observing perineal pad for bleeding.
e. encouraging leg exercises to promote circulation.

a. monitoring urine output.
b. changing position frequently.
e. encouraging leg exercises to promote circulation.

Rationale: After an abdominal hysterectomy, postoperative care includes monitoring urinary output because urinary retention may occur from temporary bladder atony related to edema or nerve trauma. Frequent changes of position, avoidance of the high Fowler’s position, and avoidance of pressure under the knees minimize the risk of deep vein thrombosis (DVT). Food and fluids may be restricted if the patient is nauseated. Leg exercises promote circulation. After an abdominal hysterectomy, the nurse observes the abdominal dressing for bleeding.

17

Postoperative nursing care for the woman with a gynecologic fistula includes (select all that apply)
a. ambulation.
b. bladder training.
c. warm sitz baths.
d. perineal hygiene.
e. use of stool softeners.

c. warm sitz baths.
d. perineal hygiene.

Rationale: Postoperatively, perineal hygiene is important to prevent infection. Warm sitz baths should be taken three times daily if possible.

18

The first nursing intervention for the patient who has been sexually assaulted is to
a. treat urgent medical problems.
b. contact support person for the patient.
c. provide supplies for the patient to cleanse self.
d. document bruises and lacerations of the perineum and the cervix.

a. treat urgent medical problems.

Rationale: In the care of a victim of sexual assault, shock and other urgent medical problems (e.g., head injury, hemorrhage, wounds, fractures) are treated first.

19

The nurse provides drug teaching for a 30-year-old woman who is prescribed clomiphene (Clomid). It is most important for the nurse to follow up on which patient statement?
a. “Hormone production and release will be increased.”
b. “This drug is like estrogen and is used to treat infertility.”
c. “I should avoid intercourse while taking this medication.”
d. “This medication will stimulate my ovaries to produce eggs.”

c. “I should avoid intercourse while taking this medication.”

Clomiphene is an oral medication administered for infertility. The medication is a selective estrogen-stimulation modulator that stimulates ovulation, making pregnancy after intercourse or artificial insemination more likely. The drug increases gonadotropin-releasing hormone production. In addition, the release of the follicle-stimulating hormone and luteinizing hormone is increased.

20

The nurse is caring for a 26-year-old patient who is being discharged after an induced abortion. Which statement should the nurse include in the discharge teaching?
a. “Avoid sexual intercourse for 2 weeks.”
b. “Heavy bleeding is expected for 24 hours.”
c. “A temperature of 101o F (38.9 o C) is normal”
d. “Birth control pills should not be taken for 30 days.”

a. “Avoid sexual intercourse for 2 weeks.”

After an abortion teach the patient to avoid intercourse for 2 weeks. Contraception can be started the day of the procedure. Symptoms of possible complications include a fever and abnormal vaginal bleeding. These symptoms should be reported immediately.

21

The nurse obtains a history from a 42-year-old patient diagnosed with premenstrual syndrome (PMS). It is most important for the nurse to follow up on which patient statement?
a. “Exercise is relaxing and reduces anxiety and irritability.”
b. “Milk, beans, and soy nuts may decrease symptoms of PMS.”
c. “Evening primrose oil will reduce bleeding during my period.”
d. “A low-salt diet decreases weight gain and bloating before my period.”

c. “Evening primrose oil will reduce bleeding during my period.”

Evening primrose oil may increase the risk of bleeding. Foods rich in vitamin B6 (e.g., pork, milk, egg yolk, legumes) promote serotonin production, which improves the symptoms of PMS. Aerobic exercise can have a relaxing effect and can reduce PMS clinical manifestations. Limiting salt intake and increasing calcium intake have been proposed to alleviate fluid retention, weight gain, bloating, breast swelling, and tenderness.

22

A 23-year-old woman who is admitted with a possible ectopic tubal pregnancy reports sudden intense pelvic pain radiating to the left shoulder. Which action by the nurse should receive the highest priority?
a. Observe the amount of vaginal bleeding every 15 minutes for 1 hour.
b. Check the vital signs and immediately notify the health care provider.
c. Administer the prescribed pain medication and reassess in 30 minutes.
d. Assess the fetal heart tones and determine the presence of fetal movement.

b. Check the vital signs and immediately notify the health care provider.

A ruptured ectopic pregnancy may produce pelvic or abdominal pain and vaginal bleeding. If the tube ruptures, the pain is intense and may be referred to the shoulder. External vaginal bleeding may not be an accurate indicator of actual blood loss. Vital signs should be monitored closely along with observation for signs of shock. A ruptured ectopic pregnancy is an emergency because of the risk of hemorrhage and hypovolemic shock. The patient may need a blood transfusion and IV fluid therapy. In addition, the patient will need emergency surgery. Fetal assessment is not indicated for an ectopic pregnancy.

23

The nurse is teaching health promotion to a variety of women in a community center. When asked when a female should begin having a Pap smear, how should the nurse respond?
a. Every year beginning at age 30
b. Every 3 years beginning at age 21
c. Every 3 years beginning at age 18 if sexually active
d. Every year beginning at the onset of menarche and continuing until menopause

b. Every 3 years beginning at age 21

A Pap test (Pap smear) should be done at least once every 3 years at the age of 21 regardless of when a woman becomes sexually active. Women 65 years or older may stop having Pap tests after having no abnormal Pap tests for the last 2 years.

24

The nurse is providing education to a group of perimenopausal women. Which herbs and/or supplements would the nurse include in a discussion regarding effective alternative therapies for menopausal symptoms (select all that apply)?
a. Soy
b. Garlic
c. Gingko
d. Vitamin A
e. Black cohosh

a. Soy
e. Black cohosh

There is good scientific evidence that soy is useful in decreasing menopausal hot flashes and that black cohosh is safe to use for up to 6 months to decrease menopausal symptoms. Garlic, gingko, and vitamin A do not affect menopausal symptoms.

25

What should the nurse emphasize when teaching a woman who has been diagnosed with pelvic inflammatory disease (PID)?
a. The importance of contraception
b. Benefits of hormone therapy (HT)
c. Manifestations of further infection
d. The importance of maintaining hygiene

c. Manifestations of further infection

PID frequently progresses to serious infection of the reproductive structures. The diagnosis does not present a particular need for contraception or specific hygiene measures. HT is not used to treat PID.

26

What should be included in nursing responsibilities when providing immediate care for a female patient who has experienced a sexual assault?
a. Administering a pregnancy test
b. Close monitoring of the patient's vital signs
c. Ensuring the patient is left alone when possible
d. Informing the patient about possible financial support

d. Informing the patient about possible financial support

Many sexual assault survivors are unaware of the availability of financial compensation (a law in most states) and appreciate information about the application process. A pregnancy test is premature, and the patient should not be left alone. There is rarely a specific indication for close monitoring of vital signs unless the extent of physical injury indicates a need.

27

A 58-year-old woman is one-day postoperative following an abdominal hysterectomy. Which intervention should the nurse perform in order to prevent deep vein thrombosis (DVT)?
a. Place the patient in a high Fowler's position.
b. Provide pillows to place under the patient's knees.
c. Encourage the patient to change positions frequently.
d. Teach the patient deep breathing and coughing exercises.

c. Encourage the patient to change positions frequently.

The patient should be encouraged to change positions frequently and ambulate to prevent venous stasis. The high Fowler's position and pressure under the knees should be avoided in order to prevent DVT. Deep breathing and coughing are therapeutic exercises but do not directly address the risk of DVT.

28

What should the nurse advise a woman to do who is recovering from surgical repair of a fistula?
a. Douche daily to prevent postoperative infection.
b. Remove and cleanse her pessary on a daily basis.
c. Resume normal activity to prevent adhesion formation.
d. Ensure that she does not place stress on the repaired area.

d. Ensure that she does not place stress on the repaired area.

Following surgical repair of a fistula, the patient should avoid placing stress on the repaired region. Normal activity is not commonly resumed until significant healing has occurred. Douching is contraindicated, and pessaries are used to treat prolapses, not fistulas.

29

A pregnant female is experiencing amenorrhea, morning sickness, and breast tenderness. In the ninth week after her last menstrual period, she is rushed to the hospital with severe left shoulder pain, blood pressure of 90/60 mm Hg, and heart rate of 112 beats/minute. What is the best diagnostic test to determine the cause of her problem?
a. Serum hemoglobin
b. 12-lead electrocardiogram
c. A transvaginal ultrasound
d. Serial β-human chorionic gonadotropin levels

c. A transvaginal ultrasound

Because the patient is known to be pregnant, a transvaginal ultrasound will be used to assess for ectopic pregnancy and tubal rupture. Serum hemoglobin and 12-lead ECG would not define a diagnosis related to the manifestations that she has. Serial β-human chorionic gonadotropin levels could be used if the patient was stable to determine if a spontaneous abortion is occurring, as the levels would decrease over time.

30

Because of the risks associated with hormone therapy (HT), a 50-year-old patient does not want to take HT and asks the nurse how she can handle her perimenopausal symptoms of hot flashes and sweating at night. What should the nurse first advise this patient?
a. Increase warmth to avoid chills.
b. Good nutrition to avoid osteoporosis
c. Vitamin B complex and vaginal lubrication
d. Decrease heat production and increase heat loss.

d. Decrease heat production and increase heat loss.

To avoid hot flashes and sweating at night, decrease heat production with a cool environment, limit caffeine and alcohol, and practice relaxation techniques. Heat loss may be facilitated with increased circulation in the room, avoidance of heavy bedding, and wearing loose-fitting clothes. Warmth will facilitate hot flashes. Nutrition, vitamin B complex, and vaginal lubrication will help with other complications of perimenopause, but not hot flashes and sweating at night.

31

The woman, who has finished having children, has been suffering from endometriosis and is seeking a cure. The nurse should teach this patient about what treatment?
a. Leuprolide (Lupron)
b. Danazol (Danocrine)
c. Nonsteroidal anti-inflammatory drugs
d. Surgical removal of endometrial implants

d. Surgical removal of endometrial implants

The only cure for endometriosis is the surgical removal of all endometrial implants that may include the uterus, fallopian tubes, and ovaries. Leuprolide is a gonadotropin-releasing hormone agonist that causes amenorrhea with menopausal side effects. Danazol is a synthetic androgen that inhibits the anterior pituitary. Nonsteroidal anti-inflammatory drugs relieve pain but do not affect the problem of endometriosis.

32

The patient at the clinic complains about her abdominal bloating, depression, and irritability related to her premenstrual syndrome. What should the nurse first recommend (select all that apply)?
a. Take diuretics.
b. Exercise regularly.
c. Take antidepressants.
d. Take antianxiety agents.
e. Increase pork, chicken, and milk intake.

b. Exercise regularly.
e. Increase pork, chicken, and milk intake.

The nurse can recommend regular exercise to help manage stress, elevate the mood, and have a relaxing effect. Eating foods rich in vitamin B6 (pork, milk, and legumes) and tryptophan (dairy and poultry) will promote serotonin production and improve symptoms. Diuretics, antidepressants, and antianxiety agents are not prescribed unless symptoms persist or interfere with daily functioning.

33

The nurse is caring for a 25-year-old patient who has polycystic ovary syndrome (PCOS). When preparing to teach this patient, which classic manifestation should the nurse know is associated with the severity of symptoms, including infertility?
a. Obesity
b. Hirsutism
c. Amenorrhea
d. Irregular menstrual periods

a. Obesity

Obesity has been associated with the severity of symptoms such as excess androgens, oligorrhea, amenorrhea, and infertility. This knowledge will affect the teaching the nurse does for this patient to prevent cardiovascular disease and abnormal insulin resistance. Hirsutism, amenorrhea, and irregular menstrual periods are not associated with the severity of the symptoms.

34

A 60-year-old woman comes to the clinic reporting unexpected bleeding. What should the nurse tell the patient about diagnosing the cause of this bleeding?
a. "It is probably only the end of menopause."
b. "You will need a hysterectomy to treat this bleeding."
c. "You will need a Pap smear to see if you have endometrial cancer."
d. "You will need an endometrial biopsy to determine the cause of bleeding."

d. "You will need an endometrial biopsy to determine the cause of bleeding."

With unexpected bleeding in a postmenopausal woman, an endometrial biopsy should be done to exclude or diagnose endometrial cancer. The abnormal bleeding should not be ignored just because she is postmenopausal. A hysterectomy with bilateral salpingo-oophorectomy with lymph node biopsies will be done to treat endometrial cancer if it is diagnosed. A Pap smear will not diagnose endometrial cancer unless it has spread to the cervix.

35

An older male patient is experiencing difficulty in initiating voiding
and a feeling of incomplete bladder emptying. These symptoms of
BPH are primarily caused by
a. obstruction of the urethra.
b. untreated chronic prostatitis.
c. decreased bladder compliance.
d. excessive secretion of testosterone.

a. obstruction of the urethra.

Rationale: Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland. Enlargement of the prostate gradually compresses the urethra, eventually leading to partial or complete urethral obstruction. Compression of the urethra ultimately leads to development of clinical symptoms.

36

Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, the nurse should
a. deflate the catheter balloon to 10 mL to decrease bulk in the bladder.
b. deflate the catheter balloon and then reinflate to ensure that it is patent.
c. encourage the patient to try to have a bowel movement to relieve colon pressure.
d. explain that this feeling is normal and that he should not try to urinate around the catheter.

d. explain that this feeling is normal and that he should not try to urinate around the catheter.

Rationale: Bladder spasms occur as a result of irritation of the bladder mucosa from the insertion of the resectoscope, presence of a catheter, or clots that cause obstruction of the catheter. The nurse should instruct the patient not to urinate around the catheter because this increases the likelihood of spasm.

37

The nurse explains to the patient with chronic bacterial prostatitis who is undergoing antibiotic therapy that (select all that apply)
a. all patients require hospitalization.
b. pain will lessen once treatment has ended.
c. course of treatment is generally 2 to 4 weeks.
d. long-term therapy may be indicated in immunocompromised patient.
e. if the condition is unresolved and untreated, he is at risk for prostate cancer.

b. pain will lessen once treatment has ended.
d. long-term therapy may be indicated in immunocompromised patient.

Rationale: Patients with chronic bacterial prostatitis are usually given antibiotics for 4 to 12 weeks. Antibiotics may be given for a lifetime if the patient is immunocompromised. Although patients with chronic bacterial prostatitis tend to experience much discomfort, the pain resolves as the infection is treated. If the patient with acute bacterial prostatitis has high fever or other signs of impending sepsis, hospitalization and IV antibiotics are prescribed.

38

The nurse should explain to the patient who has had a vasectomy that
a. the procedure blocks the production of sperm.
b. erectile dysfunction is temporary and will return with sexual activity.
c. the ejaculate will be about half the volume it was before the procedure.
d. an alternative form of contraception will be necessary for 6 to 8 weeks.

d. an alternative form of contraception will be necessary for 6 to 8 weeks.

Rationale: After a vasectomy, the patient needs to use an alternative form of contraception until semen examination reveals no sperm. Evacuating sperm distal to the surgical site usually requires at least 10 ejaculations or 6 weeks.

39

To decrease the patient’s discomfort over care related to his reproductive organs, the nurse should
a. relate his sexual concerns to his sexual partner.
b. arrange to have male nurses care for the patient.
c. maintain a nonjudgmental attitude toward his sexual practices.
d. use technical terminology when discussing reproductive
function.

c. maintain a nonjudgmental attitude toward his sexual practices.

Rationale: Conducting routine health assessments on men places the nurse in a unique position. It provides an opportunity to ask the patient questions about general health and about sexual health and function. Given the opportunity, men are less hesitant to answer these questions when they know that someone cares and can provide them with answers. The nurse must remain nonjudgmental about sexual practices.

40

The nurse is caring for a 62-year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan?
a. Avoid straining during defecation.
b. Restrict fluids to prevent incontinence.
c. Sexual functioning will not be affected.
d. Prostate exams are not needed after surgery.

a. Avoid straining during defecation.

Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Instruct the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

41

The nurse coordinates postoperative care for a 70-year-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Teach the patient how to perform Kegel exercises.
b. Provide instructions to the patient on catheter care.
c. Administer oxybutynin (Ditropan) for bladder spasms.
d. Manually irrigate the urinary catheter to determine patency.

d. Manually irrigate the urinary catheter to determine patency.

The nurse may delegate the following to an LPN/LVN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, administer antispasmodics and analgesics as needed. A registered nurse may not delegate teaching, assessments, or clinical judgments to a LPN/LVN.

42

A 45-year-old man reports having recent problems attaining an erection. Which medication will the nurse further explore as the possible etiology of this patient’s sexual dysfunction?
a. Furosemide (Lasix)
b. Fluoxetine (Prozac)
c. Clopidogrel (Plavix)
d. Nitroglycerin (Nitrostat)

b. Fluoxetine (Prozac)

Fluoxetine is a selective serotonin reuptake inhibitor used in the treatment of depression. A common adverse effect of this medication is sexual problems (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest) in nearly 70% of men and women.

43

A 73-year-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give the patient anticipatory guidance that what condition may be developing?
a. A tumor of the prostate
b. Benign prostatic hyperplasia
c. Bladder atony because of age
d. Age-related altered innervation of the bladder

b. Benign prostatic hyperplasia

Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

44

To accurately monitor progression of a symptom of decreased urinary stream, the nurse should encourage the patient to have which primary screening measure done on a regular basis?
a. Uroflowmetry
b. Transrectal ultrasound
c. Digital rectal examination (DRE)
d. Prostate-specific antigen (PSA) monitoring

c. Digital rectal examination (DRE)

Digital rectal examination is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.

45

A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient?
a. The patient requires two tablets of Tylenol #3 during the night.
b. The patient complains of fatigue and claims to have minimal appetite.
c. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased.
d. The patient has expressed anxiety about his planned discharge home the following day.

c. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased.

A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

46

A 71-year-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention?
a. Resumption of normal urinary drainage
b. Maintenance of normal sexual functioning
c. Prevention of acute or chronic renal failure
d. Prevention of fluid and electrolyte imbalances

a. Resumption of normal urinary drainage

The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.

47

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy?
a. Assessing the patient's incision
b. Irrigating the patient's Foley catheter
c. Assessing the patient's pain and selecting analgesia
d. Performing cleansing of the meatus and perineal region

d. Performing cleansing of the meatus and perineal region

Performing perineal care is an appropriate task for delegation. Selecting analgesia, irrigating the patient's catheter, and assessing his incision are not appropriate skills or tasks for unlicensed personnel.

48

A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)?
a. E. coli bacteria in his urine
b. A very tender prostate gland
c. Complaints of chills and rectal pain
d. Complaints of urgency and frequency

b. A very tender prostate gland

A tender and swollen prostate is indicative of prostatis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatis.

49

After a vasectomy, what teaching should be included in the discharge teaching?
a. "You will want to use an alternative form of contraception for 6 weeks."
b. "You may lose some secondary sexual characteristics after this surgery."
c. "You may have erectile dysfunction for several months after this surgery."
d. "You will be uncomfortable, but you may safely have sexual intercourse today."

a. "You will want to use an alternative form of contraception for 6 weeks."

As vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm, usually at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.

50

The patient has had cardiovascular disease for some time and has now developed erectile dysfunction. He is frustrated because he cannot take erectogenic medications because he takes nitrates for his cardiac disease. What should the nurse do first to help this patient?
a. Give the patient choices for penile implant surgery.
b. Recommend counseling for the patient and his partner.
c. Obtain a thorough sexual, health, and psychosocial history.
d. Assess levels of testosterone, prolactin, LH, and thyroid hormones.

c. Obtain a thorough sexual, health, and psychosocial history.

The nurse's first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.

51

A normal male reproductive function that may be altered in a patient who undergoes a prostatectomy is
a. sperm production.
b. production of testosterone.
c. production of seminal fluid.
d. release of sperm from the epididymis.

c. production of seminal fluid.

Rationale: The seminal vesicles, prostate gland, and Cowper’s (bulbourethral) glands are the accessory glands of the male reproductive system. The glands produce and secrete seminal fluid (i.e., semen), which contains the sperm and forms the ejaculate.

52

Estrogen production by a mature ovarian follicle causes
a. decreased secretion of FSH and LH.
b. increased production of GnRH and FSH.
c. release of GnRH and increased secretion of LH.
d. decreased release of FSH and decreased progesterone production.

c. release of GnRH and increased secretion of LH.

Rationale: Increased levels of circulating estrogen result in greater levels of gonadotropin-releasing hormone (GnRH), which cause the pituitary gland to release increased levels of luteinizing hormone (LH).

53

Female orgasm is the result of (select all that apply)
a. constriction of the cervical os.
b. uterine and vaginal contractions.
c. vaginal enlargement and uterine elevation.
d. clitoral swelling and increased vaginal lubrication.
e. rapid release of muscular tension in the reproductive structures.

b. uterine and vaginal contractions.
c. vaginal enlargement and uterine elevation.
d. clitoral swelling and increased vaginal lubrication.
e. rapid release of muscular tension in the reproductive structures.

Rationale: In the female orgasmic phase, contractions occur in the uterus from the fundus to the lower uterine segment, and there are rhythmic contractions of the vagina. The vagina enlarges, and the uterus is elevated. Muscular tension is rapidly released through rhythmic contractions in the clitoris, the vagina, and the uterus. The cervical os dilates to facilitate the entrance of sperm.

54

An age-related finding noted by the nurse during the assessment of the older woman’s reproductive system is
a. dyspareunia.
b. vaginal dryness.
c. nipple retraction.
d. increased sensitivity of labia.

b. vaginal dryness.

Rationale: With advancing age, changes occur in the female reproductive system. Many of these changes are related to the alteration in estrogen production that is associated with menopause. A reduction in circulating estrogen and an increase in androgens in postmenopausal women are associated with breast and genital atrophy, reduction in bone mass, and increased rate of atherosclerosis. Vaginal dryness may occur and can lead to urogenital atrophy and changes in the quantity and composition of vaginal secretions.

55

Significant information about a patient’s past health history related to the reproductive system should include
a. extent of sexual activity.
b. general satisfaction with sexuality.
c. previous sexually transmitted infections.
d. self-image and relationships with others.

c. previous sexually transmitted infections.

Rationale: The health history should include information about major illnesses, hospitalizations, immunizations, and operations. The nurse should inquire about any infections involving the reproductive system, including sexually transmitted infections (STIs).

56

To evaluate the female patient’s breasts, the nurse would use the examination technique of (select all that apply)
a. palpation.
b. inspection.
c. percussion.
d. auscultation.

a. palpation.
b. inspection.

Rationale: When performing the physical assessment of the female breasts, the nurse uses palpation and inspection techniques.

57

An abnormal finding noted during physical assessment of the male reproductive system is
a. descended testes.
b. symmetric scrotum.
c. slight clear urethral discharge.
d. the glans covered with prepuce.

c. slight clear urethral discharge.

Rationale: In physical assessment of the male external genitalia, normal findings include diamond-shaped hair distribution and a circumcised or uncircumcised penis. (In circumcision, the prepuce is removed.) If the male patient is uncircumcised, the glans is covered by the prepuce; no penile lesions or penile discharge is observed; the scrotum is symmetric, no masses are identified, testes are descended; and no inguinal hernia is detected. Urethral discharge is an abnormal finding.

58

The nurse is caring for a patient scheduled for an endometrial biopsy who is having difficulty becoming pregnant. The nurse explains to the woman that
a. the outpatient procedure is usually done preovulation.
b. bleeding and discharge are common 2 to 4 days after the procedure.
c. a small sample of tissue is obtained to diagnose and treat cervical dysplasia.
d. common changes in endometrial cells in relation to progesterone levels will be assessed.

d. common changes in endometrial cells in relation to progesterone levels will be assessed.

Rationale: Endometrial biopsy may be performed in cases of infertility to confirm that the lining of the uterus (endometrium) is going through the normal menstrual cycle changes, including progesterone secretion after ovulation. The procedure may also be performed to assess abnormal menstrual or postmenopausal uterine bleeding. Uterine cramping may occur during the procedure. A light amount of bloody vaginal bleeding may occur for about 24 hours after the procedure.

59

A 62-year-old male patient with hypertension is prescribed amlodipine (Norvasc). The nurse should assess for which possible adverse effect?
a. Gynecomastia
b. Increased sex drive
c. Erectile dysfunction
d. Prostate gland enlargement

c. Erectile dysfunction

Some antihypertensive medications (e.g., amlodipine) may cause erectile dysfunction (or impotence), decreased sex drive, and difficulty achieving orgasm.

60

The nurse performs a breast examination on a 26-year-old female patient 1 week after her menstrual period. The patient reports that she has never been pregnant. Which finding, if made by the nurse, would indicate a normal breast examination?
a. Nipples are soft without retractions.
b. Unilateral breast dimpling is present.
c. Milky fluid is expressed from the nipples.
d. Axillary lymph nodes are fixed and palpable.

a. Nipples are soft without retractions.

Normal breasts are symmetric without dimpling. Nipples are soft with no drainage, retraction, or lesions noted. No masses, tenderness, or lymphadenopathy is present.

61

The nurse is obtaining a sexual history from a 50-year-old sexually active woman who is a new patient in the primary care clinic. It would be most appropriate for the nurse to ask which question first?
a. “Have you ever had a sexually transmitted infection?”
b. “Have you ever been in a relationship with anyone who hurt you?”
c. “Have you ever been forced into sexual acts as a child or an adult?”
d. “Are you satisfied with your sexual relationship with your partner?”

d. “Are you satisfied with your sexual relationship with your partner?”

When taking a sexual health history, the nurse should begin with the least sensitive area of questioning and then move to more sensitive areas.

62

The nurse is teaching a 56-year-old male patient about routine health screenings. Which statement, if made by the patient, indicates that teaching has been successful?
a. “Testosterone testing also screens for prostate cancer.”
b. “Testicular self-examinations should be done until age 60.”
c. “Prostate-specific antigen testing screens for testicular cancer.”
d. “Prostate examination may need to be done every year starting at age 50.”

d. “Prostate examination may need to be done every year starting at age 50.”

Starting at age 50, men should discuss with their health care provider the risks and benefits of annual prostate cancer screening with specific antigen (PSA) blood testing and a digital rectal examination (DRE). Men at high risk for prostate cancer (e.g., African Americans, men with prostate cancer in first-degree relatives) should begin these discussions earlier with their provider. Testosterone testing is not used for screening purposes. Testicular self-examination should be initiated during adolescence and continue indefinitely.

63

A 21-year-old woman is scheduled for her first Pap test. The nurse should provide which instructions?
a. “A full bladder is needed for more accurate results.”
b. “You should rest for 2 to 3 hours after the procedure.”
c. “Do not douche for at least 24 hours before the procedure.”
d. “A Pap test will screen for sexually transmitted infections.”

c. “Do not douche for at least 24 hours before the procedure.”

The patient should be instructed to not douche for at least 24 hours before a Pap test. The patient should empty the bladder before a Pap test. There are no activity restrictions after a Pap test. The patient should rest for 2 to 3 days after a conization. A culture or a smear tests for sexually transmitted infections. A Pap test is a cytologic study used to detect abnormal cells.

64

What is an abnormal finding the nurse should identify during physical assessment of the female reproductive system?
a. Dimpling of breast
b. Dark pink genitalia
c. Watery cervical mucus
d. Triangular hair distribution

a. Dimpling of breast

Dimpling of the breast is highly suspicious for carcinoma of the breast. Dark pink genitalia, watery cervical mucus, and triangular pubic hair distribution are all normal female reproductive system assessment findings.

65

Which male patient is most susceptible to experiencing erectile dysfunction as a consequence of his drug regimen?
a. A patient who has been prescribed a β-adrenergic blocker for hypertension
b. A patient who uses a proton pump inhibitor (PPI) to control his acid reflux
c. A patient who is taking a cephalosporin antibiotic in order to treat cellulitis
d. A patient who takes a selective serotonin reuptake inhibitor (SSRI) to treat his depression

a. A patient who has been prescribed a β-adrenergic blocker for hypertension

Antihypertensives are commonly implicated in cases of erectile dysfunction. Antibiotics, PPIs, and SSRIs are less likely to negatively impact men's sexual function.

66

The nurse is performing an admission assessment of a 70-year-old male patient prior to bladder resection surgery. What assessment finding of the patient's genitourinary system constitutes an unexpected finding?
a. The patient's left testicle hangs lower than his right.
b. Pubic hair is absent from the patient's genital region.
c. The patient's intestines are not palpable through the inguinal rings.
d. The patient's foreskin can be manually retracted to expose the meatus.

b. Pubic hair is absent from the patient's genital region.

An absence of pubic hair is an unexpected finding in the older male patient. It is common for the left testicle to hang lower than the right, and the intestines are often not palpable through the inguinal rings. The foreskin should be easily retractable.

67

A 48-year-old woman has sought care because of urinary incontinence. The woman states that running or jumping often precipitates leakage of urine, an event that has been occurring with increasing regularity in recent months. Which assessment question is most relevant to try to determine the cause of the patient's problem?
a. "Do you find that you are prone to frequent urinary tract infections (UTIs)?"
b. "Do you know if your mother or sisters have experienced similar problems?"
c. "Did you experience any muscle damage when giving birth to your children?"
d. "Do you participate in a regular program of physical exercise and stretching?"

c. "Did you experience any muscle damage when giving birth to your children?"

Trauma to the pelvic musculature during birth is often the cause of urge and stress incontinence in female patients. UTIs, family history, and exercise are less likely to contribute to an ongoing pattern of incontinence.

68

A 58-year-old male patient with a history of transient ischemic attacks (TIAs) is undergoing rehabilitation following an ischemic stroke. The patient's medical history is likely to be related to what health problems?
a. Inguinal hernia
b. Erectile dysfunction
c. Testosterone deficiency
d. Benign prostatic hyperplasia (BPH)

b. Erectile dysfunction

Stroke is a common cause of erectile dysfunction. A stroke and underlying cardiovascular disease is unlikely to be related to an inguinal hernia, testosterone deficiency, or BPH.

69

A 78-year-old female is complaining about hair growing on her chin. How should the nurse explain this occurrence to this patient?
a. There is too much estrogen in your body.
b. There must not be enough testosterone in your body.
c. The estrogen in your body is decreased since menopause.
d. The negative feedback system for your hormones is working.

c. The estrogen in your body is decreased since menopause.

Many of the reproductive changes associated with aging for women occur related to the altered ability to produce estrogen associated with menopause. Postmenopausally there may be increased androgens. Estrogen stimulation is related to negative feedback, and GnRH would stimulate greater follicle-stimulating hormone (FSH) and leutinizing hormone (LH), which results in a higher level of estrogen production by the ovaries. The negative feedback mechanism is not active because this system occurs when there is decreased level of circulating estrogen, which increases the level of GnRH production by the hypothalamus, leading to increased FSH and LH from the pituitary, which results in higher estrogen production.

70

At the clinic, the mother asks the nurse about how to teach her daughter about menstruation. What should the nurse include when assisting this mother?
a. The length of the menstrual cycle should be 28 days.
b. Menstrual cycles are often irregular for the first 1 to 2 years.
c. The female loses approximately 1 cup of blood with each menstrual period.
d. Follicle-stimulating hormone (FSH) causes full maturity of the follicle for ovulation.

b. Menstrual cycles are often irregular for the first 1 to 2 years.

Teaching the mother that the menstrual cycles are often irregular for the first 1 to 2 years will reassure the mother and the daughter if the daughter's cycle is irregular at first. The length of a menstrual cycle may be from 21 to 35 days, with the average length being 28 days. Approximately 20-80 mL (which at most is only 1/3 cup) of blood is lost with each menstrual period. FSH begins the follicle maturation, but LH must be present for complete maturation and ovulation to occur.

71

When teaching nursing students about the male sexual response, what should the nurse call the phase that has ejaculation?
a. Plateau phase
b. Orgasmic phase
c. Resolution phase
d. Excitement phase

b. Orgasmic phase

The orgasmic phase is when ejaculation occurs from contraction of the penile and urethral musculature propelling the sperm outward through the meatus. The excitement phase is manifest by penile erection in response to sexual stimulation. The plateau phase is when the erection is maintained, and there is a slight increase in vasocongestion and testicle size, and the glans penis may become more reddish-purple. The resolution phase is after ejaculation when the penis gradually returns to its unstimulated, flaccid state.

72

The patient has been told she will have blood drawn for a test and asks the nurse, "What is a prolactin assay for?" What is the best response by the nurse?
a. "It will tell you if you are pregnant."
b. "It is used to detect a cause of amenorrhea."
c. "It will tell us if you have a reproductive malignancy."
d. "It can indicate if you need to be tested for a sexually transmitted infection."

b. "It is used to detect a cause of amenorrhea."

A prolactin assay will detect pituitary dysfunction that can cause amenorrhea. Human chorionic gonadotropin (hCG) is used to detect pregnancy. The biologic tumor markers, α-fetoprotein, hCG, and CA 125 may be used to assess for reproductive malignancies and to monitor therapy. Venereal disease research laboratory (VDRL) is a nonspecific antibody test used to screen for syphilis, a sexually transmitted infection.

73

You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). 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.

3. The bladder is palpable above the symphysis pubis and the client is restless.

Rationale:
A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required.

74

While performing a breast examination on a 22-year-old client, you obtain the following 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.

4. An irregularly shaped, nontender lump is palpable in the left breast.

Rationale:
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 ultrasound. The other information is not unusual and does not indicate the need for immediate action.

75

After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit (PACU). Which nursing action is best to delegate 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

1. Monitoring the client's dressing for any signs of bleeding

Rationale:
An LPN/LVN working in a PACU 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.

76

You are working with UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate 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

2. Elevating the client's arm on two pillows to promote lymphatic drainage

Rationale:
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.

77

You obtain the following assessment data about your 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 pulled taut and taped to the client's thigh.
4. The client reports painful bladder spasms.

4. The client reports painful bladder spasms.

Rationale:
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.

78

A 67-year-old client with BPH has a new prescription for tamsulosin (Flomax). 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 will decrease as a result of taking this medication."
4. "You should avoid sitting up or standing up too quickly."

4. "You should avoid sitting up or standing up too quickly."

Rationale:
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.

79

You are caring for a client who has just returned to the surgical unit after a 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 reports of abdominal cramping

2. Catheter that is draining deep red blood

Rationale:
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.

80

After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be delegated to an experienced 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

1. Reinforcing the client's need to check his temperature daily

Rationale:
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.

81

The day after a radical prostatectomy, your 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 you take first?
1. Irrigate the catheter with 50 mL of sterile saline.
2. Administer oxybutynin (Ditropan) 5 mg orally.
3. Apply warm packs to the client's right calf.
4. Measure oxygen saturation using pulse oximetry.

4. Measure oxygen saturation using pulse oximetry.

Rationale:
It is important to assess oxygenation, because the client's calf tenderness and shortness of breath suggest a possible deep vein thrombosis and pulmonary embolus, serious complications of TURP. The other activities are appropriate but are not as high a priority as ensuring that oxygenation is adequate.

82

After arriving for your shift in the emergency department (ED), you receive a change-of-shift report about all of these clients. Which one do you need to assess first?
1. 19-year-old with scrotal swelling and severe pain that has not decreased with elevation of the scrotum
2. 25-year-old who has a painless indurated lesion on the glans penis
3. 44-year-old with an elevated temperature, chills, and back pain associated with recurrent prostatitis
4. 77-year-old with abdominal pain and acute bladder distention

1. 19-year-old with scrotal swelling and severe pain that has not decreased with elevation of the scrotum

Rationale:
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 and urinary retention), which also need rapid assessment and intervention, but these are not as urgent as the possible testicular torsion.

83

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

3. The client uses sildenafil (Viagra) several times weekly for erectile dysfunction.

Rationale:
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 and/or teaching, but it is essential for the client who uses nitrates to avoid concurrent use of sildenafil.

84

You are working on the PACU 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 (out of 10) abdominal pain

4. Sharp, continuous, level 8 (out of 10) abdominal pain

Rationale:
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 due to the stress response after surgery. Bleeding following the procedure is expected but should decrease over the first 2 hours. And although the oxygen saturation is not at an unsafe level, interventions to improve the saturation should be carried out.

85

When you are developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will you delegate 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

2. Helping the client to connect the catheter to the leg bag
4. Assisting the client in ambulating for increasing distances
5. Helping the client shower at least every other day

Rationale:
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.

86

You are working in the ED when a client with possible toxic shock syndrome is admitted. Which prescribed intervention will you implement first?
1. Remove the client's tampon.
2. Obtain blood specimens for culture.
3. Give acetaminophen (Tylenol) 650 mg.
4. Infuse nafcillin (Unipen) 1000 mg IV.

1. Remove the client's tampon.

Rationale:
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).

87

A client who underwent 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 you implement first?
1. Insert a straight catheter PRN for output of less than 300 mL/8 hr.
2. Administer acetaminophen (Tylenol) 650 mg orally.
3. Send a urine specimen to the laboratory for culture and sensitivity testing.
4. Administer ceftizoxime (Cefizox) 1 g IV every 12 hours.

1. Insert a straight catheter PRN for output of less than 300 mL/8 hr.

Rationale:
The client has symptoms of a urinary tract infection. Inserting a straight catheter will enable you 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 once the urine specimen is obtained. Administration of acetaminophen is the lowest priority, because the client's temperature is not dangerously elevated.

88

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 you act most rapidly?
1. The oral temperature is 100.7° F (38.2° C).
2. The abdomen is firm and tender to palpation above the symphysis pubis.
3. Breath sounds are decreased, with fine crackles audible at both bases.
4. The apical pulse is 86 beats/min and slightly irregular.

2. The abdomen is firm and tender to palpation above the symphysis pubis.

Rationale:
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 physician 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.

89

You are providing orientation for a new RN on the medical-surgical unit. The new RN takes the following actions while 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

3. Positioning the client flat in bed while helping her take a bath

Rationale:
The client should be positioned in a semi-Fowler position to minimize the risk of abscess development higher in the abdomen. The 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.

90

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

3. Client has a positive pregnancy test

Rationale:
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 for females and males, but it may be started up through age 26. HPV immunization is most effective in preventing HPV infection and cervical cancer when it is started before the individual is sexually active and prior to any HPV infection, but these are not contraindications for vaccination.

91

Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you 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.

2. Cover the wound with saline-soaked dressings.

Rationale:
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. Since national guidelines addressing the use of Rapid Response Teams (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 once further assessments of the client (i.e., pulse and blood pressure) are obtained. Wound cultures may be obtained, but protection of the wound, further assessment of the client, then notification of the surgeon so that other actions can be taken are the priority.