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6 P's - correct answer- Pain
Pulse
Pallor
Paresthesia
Paralysis
Perishingly cold
515. The nurse is instructing a client to perform a
testicular self-examination (TSE). The nurse should
provide the client with which information about the
procedure?
1. To examine the testicles while lying down
2. That the best time for the examination is after
a shower
3. To gently feel the testicle with 1 finger to feel for
,a growth
4. That TSEs should be done at least every 6 months -
correct answer- 515. 2
Rationale: The TSE is recommended monthly after a warm
bath or shower when the scrotal skin is relaxed.
519. The nurse is assessing the perineal wound in a client
who has returned from the operating room following an
abdominal perineal resection and notes serosanguineous
drainage from the wound. Which nursing intervention is
most appropriate?
1. Clamp the surgical drain.
2. Change the dressing as prescribed.
3. Notify the health care provider (HCP).
4. Remove and replace the perineal packing. - correct
answer- 519. 2
Rationale: Immediately after surgery, profuse
serosanguineous drainage from the perineal wound is
expected. Therefore, the nurse should change the
dressing as prescribed.
,520. The nurse is assessing the colostomy of a client who
has had an abdominal perineal resection for a bowel
tumor. Which assessment finding indicates that the
colostomy is beginning to function?
1. The passage of flatus
2. Absent bowel sounds
3. The client's ability to tolerate food
4. Bloody drainage from the colostomy - correct
answer- 520. 1
Rationale: Following abdominal perineal resection, the
nurse would expect the colostomy to begin to function
within 72 hours after surgery, although it may take up to 5
days.
521. The nurse is reviewing the history of a client with
bladder cancer. The nurse expects to note documentation
of which most common sign or symptom of this type of
cancer?
1. Dysuria
2. Hematuria
3. Urgency on urination
, 4. Frequency of urination - correct answer- 521.
2
Rationale: The most common sign in clients with cancer
ofthe bladder is hematuria. The client also may
experience irritative voiding symptoms such as frequency,
urgency, and dysuria, and these symptoms often are
associated with carcinoma in situ.
714. A client complains of fever, perineal pain, and urinary
urgency, frequency, and dysuria. To assess whether the
client's problem is related to bacterial prostatitis, the
nurse reviews the results of the prostate examination for
which characteristic of this disorder?
1. Soft and swollen prostate gland
2. Swollen, and boggy prostate gland
3. Tender and edematous prostate gland
4. Tender, indurated prostate gland that is warm to
the touch - correct answer- 714. 4
Rationale: The client with bacterial prostatitis has a
swollen and tender prostate gland that is also warm to
the touch, firm, and indurated.