TEST BANK For Lewis
A 63-year-old woman undergoes an anterior and posterior (A&P)
colporrhaphy for repair of a cystocele and rectocele. Which nursing
action will be included in the postoperative care plan? - ANSPerform indwelling catheter care.
A 54-year-old patient is on the surgical unit ...
TEST BANK For Lewis
A 63-year-old woman undergoes an anterior and posterior (A&P)
colporrhaphy for repair of a cystocele and rectocele. Which nursing
action will be included in the postoperative care plan? - ANS-
Perform indwelling catheter care.
A 54-year-old patient is on the surgical unit after a radical
abdominal hysterectomy. Which finding is MOST important to report
to the health care provider? - ANS-A. Urine output of 125 mL in the
first 8 hours after surgery
b. Decreased bowel sounds in all four abdominal quadrants
c. One-inch area of bloody drainage on the abdominal dressing
d. Complaints of abdominal pain at the incision site with coughing
Rational:
The decreased urine output indicates possible low blood volume
and further assessment is needed to assess for possible internal
bleeding. Decreased bowel sounds, minor drainage on the dressing,
and abdominal pain with coughing are expected after this surgery.
Which topic will the nurse include in the preoperative teaching for a
patient admitted for an abdominal hysterectomy? - ANS-A. Purpose
of ambulation and leg exercises
b. Adverse effects of systemic chemotherapy
c. Decrease in vaginal sensation after surgery
d. Symptoms caused by the drop in estrogen level
Rational:
Venous thromboembolism (VTE) is a potential complication after
the surgery, and the nurse will instruct the patient about ways to
prevent it. Vaginal sensation is decreased after a vaginal
hysterectomy but not after abdominal hysterectomy. Leiomyomas
are benign tumors, so chemotherapy and radiation will not be
,prescribed. Because the patient will still have her ovaries, the
estrogen level will not decrease.
The nurse in the women's health clinic has four patients who are
waiting to be seen. Which patient should the nurse see FIRST? -
ANS-a. 22-year-old with persistent red-brown vaginal drainage 3
days after having balloon thermotherapy
b. 42-year-old with secondary amenorrhea who says that her last
menstrual cycle was 3 months ago
c. 35-year-old with heavy spotting after having a progestin-
containing IUD (Mirena) inserted a month ago
D. 19-year-old with menorrhagia who has been using
superabsorbent tampons and has fever with weakness Rational:
The patients history and clinical manifestations suggest possible
toxic shock syndrome, which will require rapid intervention. The
symptoms for the other patients are consistent with their diagnoses
and do not indicate life-threatening complications.
A healthy 28-year-old who has been vaccinated against human
papillomavirus (HPV) has a normal Pap test. Which information will
the nurse include in patient teaching when calling the patient with
the results of the Pap test? - ANS-Pap testing is recommended every
3 years for women your age.
To prevent pregnancy in a patient who has been sexually assaulted,
the nurse in the emergency department will plan to teach the
patient about the use of - ANS-levonorgestrel (Plan-B One-Step).
Rational:
Plan B One-Step reduces the risk of pregnancy when taken within 72
hours of intercourse. The other methods are used for therapeutic
abortion, but not for pregnancy prevention after unprotected
intercourse.
, A 22-year-old tells the nurse that she has not had a menstrual
period for the last 2 months. Which action is MOST important for the
nurse to take? - ANS-A. Obtain a urine specimen for a pregnancy
test.
b. Ask about any recent stressful lifestyle changes.
c. Measure the patients current height and weight.
d. Question the patient about prescribed medications. Rational:
Pregnancy should always be considered a possible cause of
amenorrhea in women of childbearing age. The other actions are
also appropriate, but it is important to check for pregnancy in this
patient because pregnancy will require rapid implementation of
actions to promote normal fetal development such as changes in
lifestyle, folic acid intake, etc.
Which information will the nurse include when teaching a patient
who has developed a small vesicovaginal fistula 2 weeks into the
postpartum period? - ANS-a. Take stool softeners to prevent fecal
contamination of the vagina.
b. Limit oral fluid intake to minimize the quantity of urinary drainage.
C. Change the perineal pad frequently to prevent perineal skin
breakdown.
d. Call the health care provider immediately if urine drains from the
vagina.
Rational:
Because urine will leak from the bladder, the patient should plan to
use perineal pads and change them frequently. A high fluid intake is
recommended to decrease the risk for urinary tract infections.
Drainage of urine from the vagina is expected with vesicovaginal
fistulas. Fecal contamination is not a concern with vesicovaginal
fistulas.
The nurse has just received change-of-shift report about the
following four patients. Which patient should be assessed FIRST? -
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