Nursing Elites

1. The nurse is instructing a client to perform a testicular self-examination (TSE). What information should the nurse provide about the procedure?

• A. To examine the testicles while lying down
• B. That the best time for the examination is after a shower
• C. To gently feel the testicle with one finger to feel for a growth
• D. That testicular self-examinations should be done at least every 6 months

Correct answer: B

Rationale: The correct answer is B. The best time to perform a testicular self-examination is after a warm shower when the scrotal skin is relaxed. This makes it easier to detect any abnormalities. Choice A is incorrect because the examination should ideally be done while standing. Choice C is incorrect as the client should use both hands to roll each testicle between the thumb and fingers to feel for any lumps or changes in size. Choice D is incorrect because testicular self-examinations are recommended to be done monthly, not every 6 months, to monitor changes in the testicles.

2. The nurse is caring for a client who is postoperative following a pelvic exenteration, and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?

• A. Bowel sounds
• B. Ability to ambulate
• C. Incision appearance
• D. Urine specific gravity

Correct answer: A

Rationale: The correct answer is A: Bowel sounds. Checking for bowel sounds is crucial before administering any diet to ensure the gastrointestinal tract is functioning properly following surgery. This assessment helps prevent complications such as paralytic ileus. Choices B, C, and D are not the priority in this situation. While the ability to ambulate, incision appearance, and urine specific gravity are important assessments, ensuring bowel function takes precedence in this postoperative scenario.

3. A patient was admitted with gastric cancer. The patient asks the nurse about things to expect while receiving chemotherapy. Which of the following statements of the nurse shows incompetence?

• A. You can expect hair loss, but do not worry it will grow back immediately
• B. You may be infected easily, so avoid going to overpopulated places
• C. We may need to monitor your uric acid levels
• D. We may need to monitor your RBCs

Correct answer: A

Rationale: While hair loss (alopecia) is a common side effect of chemotherapy due to the damage to rapidly dividing hair follicle cells, the statement that hair will grow back "immediately" is inaccurate and misleading. Hair regrowth after chemotherapy takes time, typically starting a few weeks to months after treatment ends. The new hair may also have a different texture or color initially. Therefore, this statement indicates a lack of understanding and could give the patient unrealistic expectations, which is why it shows incompetence.

4. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

• A. Call the health care provider (HCP).
• B. Reinsert the implant into the vagina.
• C. Pick up the implant with gloved hands and flush it down the toilet.
• D. Pick up the implant with long-handled forceps and place it in a lead container.

Correct answer: D

Rationale: When caring for a client with an internal cervical radiation implant, safety measures must be followed to protect both the client and healthcare personnel from radiation exposure. If the implant becomes dislodged and is found in the bed, the nurse’s priority is to handle it safely using long-handled forceps, as direct contact with the implant could result in radiation exposure. The implant should be placed in a lead-lined container, which is specifically designed to shield against radiation, to prevent further contamination or exposure. After securing the implant, the nurse should notify the radiation safety officer or healthcare provider for further guidance.

5. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to:

• A. Restrict all visitors
• B. Restrict fluid intake
• C. Teach the client and family about the need for hand hygiene
• D. Insert an indwelling urinary catheter to prevent skin breakdown

Correct answer: C

Rationale: In clients experiencing neutropenia due to chemotherapy, the immune system is significantly compromised, leaving the client highly susceptible to infections. Meticulous hand hygiene is one of the most effective ways to prevent infections in neutropenic patients. Teaching the client and their family the importance of frequent and proper handwashing helps reduce the transmission of harmful pathogens that could lead to severe infections in the neutropenic client. This simple but essential intervention is crucial in maintaining a safe environment.

Similar Questions