ACCURATE SPRING- SUMMER COMPLETE 5 VERSIONS
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM PREP
The nurse is providing postoperative instructions for a female client after a
mastectomy. Which information should the nurse include in the teaching plan?
(Select all that apply.)
A) Empty surgical drains once a week using procedure gloves.
B) Report inflammation of the incision site or the affected arm.
C) Wear clothing with snug sleeves over the arm on the operative side.
D) Avoid lifting more than 4.5 kg (10 lb) or reaching above her head. - Correct
Answer - Correct Answer(s): B, D
* Part of the client's teaching plan should include reporting evidence of
inflammation at the incision or of the affected arm (B), and to avoid lifting or
reaching (D), which places the client at risk for injury to the extremity that may
have compromised lymphatic drainage. The client should be instructed to empty
surgical drains daily, not (A). Activity that decreases circulation (C) in the affected
arm, such as carrying a handbag over the shoulder, wearing tight clothing, or tight
jewelry, should be avoided.
Which sexually transmitted infection (STI) should the nurse include in a client's
teaching plan about the risk for cervical cancer?
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,A) Neisseria gonorrhoea.
B) Chlamydia trachomatis.
C) Herpes simplex virus.
D) Human papillomavirus. - Correct Answer - Correct Answer(s): D
* Human papillomavirus (D) is known to alter cervical epithelium cytology, which
is consistent with early changes of cervical cancer. Although STIs (A, B, and C)
place the client at risk for exposure to HPV, these are likely to place the client at
risk for pelvic inflammatory disease, infertility sequela, and painful reoccurrence.
A client who returns to the unit after having a percutaneous transluminal
coronary angioplasty (PTCA) complains of acute chest pain. What action should
the nurse implement next?
A) Inform the healthcare provider.
B) Obtain a 12-lead electrocardiogram.
C) Give a sublingual nitroglycerin tablet.
D) Administer prescribed analgesic. - Correct Answer - Correct Answer(s): C
* After a percutaneous transluminal coronary angioplasty (PTCA), a client who
experiences acute chest pain may be experiencing cardiac ischemia related to
restenosis, stent thrombosis, or acute coronary syndrome involving any coronary
artery. The first action is to administer nitroglycerin (C) to dilate the coronary
arteries and increase myocardial oxygenation. Then, (A, B, and D) are
implemented.
A client is admitted to the Emergency Department with a tension pneumothorax.
Which assessment should the nurse expect to identify?
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,A) An absence of lung sounds on the affected side.
B) An inability to auscultate tracheal breath sounds.
C) A deviation of the trachea toward the side opposite the pneumothorax.
D) A shift of the point of maximal impulse to the left, with bounding pulses. -
Correct Answer - Correct Answer(s): C
* Tension pneumothorax is caused by rapid accumulation of air in the pleural
space, causing severely high intrapleural pressure. This results in collapse of the
lung, and the mediastinum shifts toward the unaffected side, which is
subsequently compressed (C). (A, B, and D) are not demonstrated with a tension
pneumothorax.
A middle-aged male client asks the nurse what findings from his digital rectal
examination (DRE) prompted the healthcare provider to prescribe a repeat serum
prostatic surface antigen (PSA) level. What information should the nurse provide?
A) A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with
aging.
B) The spongy or elastic texture of the prostate is normal and requires no further
testing.
C) An infection is usually present when the prostate indents when a finger is
pressed on it.
D) Stony, irregular nodules palpated on the prostate should be further evaluated.
- Correct Answer - Correct Answer(s): D
* PSA levels are prescribed to screen for prostatic cancer which is often detected
by DRE and manifested as small, hard, or stony, irregularly-shaped nodules on the
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, surface of the prostate (D). Although PSA levels are prescribed for routine
screening, the findings suggestive of BPH (A), normal texture (B) or infection (C)
do not suggest cancer of the prostate, which requires further evaluation.
What is the primary nursing diagnosis for a client with asymptomatic primary
syphilis?
A) Acute pain.
B) Risk for injury.
C) Sexual dysfunction.
D) Deficient knowledge. - Correct Answer - Correct Answer(s): D
An asymptomatic client with primary syphilis is most likely unaware of this
disease, so to prevent transmission to others and recurrence in the client, the
priority nursing diagnosis is deficient knowledge (D). Asymptomatic primary
syphilis is not painful, so (A) is not applicable at this time. Although the client is at
risk for injury (B) and sexual dysfunction (C) related to complications, teaching the
client about transmission and treatment is instrumental in preventing the
progression to systemic secondary or tertiary syphilis.
The nurse is caring for a client with human immunodeficiency virus (HIV) infection
who develops Mycobacterium avium complex (MAC). What is the most significant
desired outcome for this client?
A) Free from injury of drug side effects.
B) Return to pre-illness weight.
C) Adequate oxygenation.
D) Maintenance of intact perineal skin. - Correct Answer - Correct Answer(s): B
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