ACC Level 2 - RNSG 1443 Exam 4 Questions With Complete Solutions
.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...
.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 - 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. - 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 - 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 - 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.
.6 P's - ANSWER-Pain
Pulse
Pallor
Paresthesia
Paralysis
Perishingly cold
.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 - 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.
, .715. The nurse is collecting data from a client. Which
symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?
1. Nocturia
2. Scrotal edema
3. Occasional constipation
4. Decreased force in the stream of urine - ANSWER-715. 4
Rationale: Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia.
The stream later becomes weak and dribbling.
.724. A client is admitted to the hospital with a diagnosis
of benign prostatic hyperplasia, and a transurethral
resection of the prostate is performed. Four hours
after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which
assessment finding indicates the need to notify the health care provider (HCP)?
1. Red, bloody urine
2. Pain rated as 2 on a 0-10 pain scale
3. Urinary output of 200 mL higher than intake
4. Blood pressure, 100/50 mm Hg; pulse, 130
beats/minute - ANSWER-724. 4
Rationale: Frank bleeding (arterial or venous) may occur during the first day after surgery. Some
hematuria is usual for several days after surgery
.808. A client is being discharged to home after application of a plaster leg cast. Which statement
indicates that the client understands proper care of the cast?
1. "I need to avoid getting the cast wet."
2. "I need to cover the casted leg with warm
blankets."
3. "I need to use my fingertips to lift and move
my leg."
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