A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and
bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is
needed?
"Well, I don't have to worry about getting pregnant anymore."
"I can't wait to go on the cruise that I have planned for this summer."
"I know I will miss having sexual intercourse with my husband."
"I have asked my daughter to stay with me next week after I am discharged." ( correct answers
) "I know I will miss having sexual intercourse with my husband."
A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs
and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important
for the nurse to identify?
Increased anxiety since the transfusion began.
Drowsiness after receiving diphenhydramine (Benadryl).
Complaints of feeling cold.
Flushed skin and headache. ( correct answers ) Flushed skin and headache.
, The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse
determines the client's lower abdomen is distended and assesses dullness to percussion. What is
the priority nursing action?
Assessment of the client's vital signs.
Document the finding as the only action.
Determine the time the client last voided.
Insert a rectal tube for the passage of flatus. ( correct answers ) Determine the time the client
last voided.
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle
cell crisis. What is the most important nursing action to implement?
Limit the client's intake of oral fluids and food.
Evaluate the effectiveness of narcotic analgesics.
Encourage the client to ambulate as tolerated.
Teach the client about prevention of crises. ( correct answers ) Evaluate the effectiveness of
narcotic analgesics.
What is the priority nursing action while caring for a client on a ventilator when an electrical fire
occurs in the intensive care unit?
Tell another staff member to bring extinguishing equipment to the bedside.
Close the doors to the client's area when attempting to extinguish the fire.
Use a bag-valve-mask resuscitator while removing the client from the area.
Implement an emergency protocol to remove the client from the ventilator. ( correct answers )
Use a bag-valve-mask resuscitator while removing the client from the area.
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse