Nursing - 309 Exam 2 Questions With Detailed Collect Answers

Nursing - 309 Exam 2 Questions With Detailed Collect Answers A 15 old adolescent tells a school nurse, "I have persistent pain during my periods." What should the nurse encourage her do to? - Answer-Have a gynecologic examination. /.A 20 year old woman is being evaluated for possible toxic shock syndrome. What question would the nurse ask? - Answer-"Do you use internal contraceptives?" /.A 22 year old patient reports abdominal pain that stems to start several days before her menstrual period. What questions does the nurse ask in order to obtain a thorough menstrual history? - Answer-"How old were you when you started menstruation?" "Typically, how long does your period last?" "How would you describe your menstrual flow?" /.A 36 year old patient is diagnosed with dysfunctional uterine bleeding. During the pelvic exam, the health care provider determines that the bleeding is acute and heavy. What is the nurse's priority action? - Answer-Prepare to administer combination hormonal therapy. /.A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? - Answer-Rectal pressure. Abdominal pain. /.A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention INITIALLY should receive the lowest priority? - Answer-Teaching residual limb care. /.A client had an above the knee amputation of the left leg because of trauma from a motor vehicle collision. The health care provider orders ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's FIRST intervention? - Answer-Determine if the client has ever used crutches before. /.A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? - Answer-Use a pillow to keep the legs abducted. /.A client has a total hip replacement. Which clinical indicators of pulmonary embolism indicate that the plan to prevent postoperative thrombus formation has been ineffective? - Answer-Unilateral chest pain. Sudden onset of shortness of breath. /.A client has a total knee replacement, and a continuous passive motion device is being used. The nurse concludes that the teaching was effective when the client states, "The goal of this therapy to--" - Answer-Improve joint flexion." /.A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture? - Answer-Lie on the abdomen 30 minutes four times daily. /.A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns from the PACU with an indwelling catheter in place. What should the nurse tell the client about the PRIMARY reasons for the catheter? - Answer-Discomfort is minimized. Urinary retention is prevented. Pressure on the suture line is relieved. /.A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? - Answer-On the client's left side. /.A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client's affected extremity? - Answer-Internal rotation with extension of the knee and hip. /.A client is diagnosed with uterine fibroids, and the health care provider advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's MOST appropriate response? - Answer-"Some women may experience symptoms of menopause if their ovaries are removed with their uterus." /.A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's BEST INITIAL response? - Answer-"I can't because the eights are needed to keep the bone aligned." /.A client is ready to walk with crutches after knee surgery. Which crutch walking technique will the nurse most likely have to reinforce after the client returns from physical therapy? - Answer-Three-point /.A client past menopause undergoes an anterior posterior colporrhaphy. What should the discharge teaching include? - Answer-Eating a high fiber diet. /.A client that has prostate cancer attempts to urinate frequently, but voids in very small amounts. What is the most likely causative factor? - Answer-Retention. /.A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her prescribed medication. She tells the nurse that her mother found them very uncomfortable during her menopause. Which medication causes this side effect? - Answer-Leuprolide (Lupron) /.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. Which of these actions prescribed by the health care provider will you implement first. - Answer-Insert a straight catheter PRN for output of less than 300 mL/8 hr. /.A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. What should the nurse explain is the benefit of bearing most of the weight on the unaffected? - Answer-Will help maintain the strength of the unaffected limb /.A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the purpose of the traction? - Answer-Relieve muscle spasm and pain. /.A client with a third degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will order? - Answer-Apply moist compresses to the uterus /.A client with urinary retention, BPH, and delirium related to urosepsis. The HCP orders a catheter to be placed. What nursing action is most important for the patient's safety? - Answer-Determine if any unsafe behavior pattern exists. /.A current treatment of nonemergent dysfunctional uterine bleeding includes which medication? - Answer-Oral or patch contraceptives /.A middle aged male patient has a tight cast on his left lower leg. An early assessment variable requiring further evaluation for compartment syndrome would be: - Answer-Pain more intense than that of the injury itself. /.A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? - Answer-Painful intercourse. Bearing down sensations. /.A nurse is caring for a client in the evening after the client has had a below the knee amputation. What action should be implemented by the nurse? - Answer-Elevate the foot of the bed. /.A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor? - Answer-Loss of blood supply to the head of the femur. /.A nurse is caring for a client who had a total hip replacement. What is the priority assessment when monitoring the client for hemorrhage? - Answer-Examining the bedding under the client /.A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation? - Answer-Encouraging the client to perform ankle exercises. /.A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has an order for ambulation with slight weight bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive devise does the nurse expect the health care provider to order for this client? - Answer-Standard walker /.A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? - Answer-Toes for mobility. /.A nurse is caring for a client with a below the knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis? - Answer-Press the end of the residual limb against a pillow periodically. /.A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in a buck extension. What explanation does the nurse give the client for why the traction is being used? - Answer-Reduces muscle spasms. /.A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. On which part of the body should the nurse instruct the client to place weight? - Answer-Palms of the hands /.A nurse provides discharge teaching for a client who had a total hip replacement. Which activities to avoid identified by the client indicate an understanding of the teach? - Answer-Crossing the legs. Sitting in a low chair. /.A nurse receives a change of shift report for a client who had a total hip replacement 24 hours ago. After reviewing the client's clinical record and completing a physical assessment, which complication should the nurse conclude that the client is experiencing? - Answer-Fat embolism /.A patient had a total abdominal hysteretomy. Which patient behavior is the best indicator that she is coping and adapting successfully? - Answer-Ask questions about the wound care, but seems reluctant to do self care. /.A patient had an anterior colporrhaphy and is returning to the clinic for the follow up appointment. Which patient statement indicates that the procedure has achieved the desired therapeutic outcome? - Answer-"I have good control over my urination." /.A patient had loop electrosurgical excision procedure (LEEP) for treatment and diagnosis of cervical cancer. In the discharge instructions, what does the nurse tell the patient to expect after the procedure? - Answer-Spotting /.A patient has excessive bleeding from uterine fibroids. Which therapy stops the blood flow to the fibroids? - Answer-Endometrial ablation. /.A patient has had a pelvic examination and needs an additional diagnostic test for possible uterine leiomyomas. The nurse prepares the patient for which first choice diagnostic test? - Answer-Transvaginal ultrasound /.A patient has had a posterior colporrhaphy. What is included in the nursing care of this patient? - Answer-Administer pain medication before a bowel movement. Instruct to avoid straining during a bowel movement. Provide sitz baths. Promote a low residue (low fiber) diet. /.A patient has undergone a total hysterectomy with vaginal repair. The nurse advises her about careful intercourse and which OTC product to decrease sexual discomfort related to intercourse? - Answer-Water based lubricants. /.A patient injured a lower extremity and has been placed in a running traction. What instructions does the nurse give to the UAP? - Answer-Moving the patient or the bed during care can alter the countertraction. /.A patient is admitted to the same day surgery unit following a meniscectomy. What does post operative care for this patient include? - Answer-Perform neurovascular checks every hour for the first few hours and then every 4 hours. Check the surgical dressing for bleeding. Teach about signs and symptoms of infection. /.A patient is admitted with toxic shock syndrome. What organism is frequently associated with this syndrome when it occurs as a menstrually related infection? - Answer-Staphylococcus aureus. /.A patient is diagnosed with uterine leiomyomas. What does the nurse expect to see in the documentation for this patient as the chief presenting symptom? - Answer-Heavy vaginal bleeding. /.A patient is receiving external radiation therpay for treatment of endometrial cancer. What task does the nurse delegate to the UAP? - Answer-Assist the patient to ambulate if she feels fatigue or tiredness. /.A patient is receiving low molecular weight heparin therapy to prevent post operative deep vein thrombosis (DVT). Which routine assessments are most important for this patient during anticoagulation therapy? - Answer-Ensure that anti-embolic stockings or sequential compression devices are in use. Monitor complete blood count (CBC) and platelets counts. Check stools for occult blood. Monitor the surgical site for bleeding. /.A patient is reluctant to consider hip surgery because of fear of blood transfusion reaction. What is the nurse's BEST response? - Answer-"You could donate your own blood for several weeks before surgery." /.A patient is undergoing large volume bladder irrigation. During and after the procedure, the nurse observes the pt for confusion, muscle weakness, and increased GI motility related to which potentially adverse effect of large volume irrigation? - Answer-Hyponatremia /.A patient receiving chemotherapy treatments reports fatigue, loss of energy, and experiencing an "emotional crisis every day and my hair is falling out."