A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet on the client's right arm. Which action by the nurse would be most appropriate?

Call the surgeon to perform a femoral puncture.

Assist in holding the client's arm still.

Tell the technician to obtain the blood sample from the client's left arm.

Suggest a finger stick be done on one of the client's left fingers.

Answer and Explanation

The Correct Answer is C

Choice A: Call the surgeon to perform a femoral puncture. This action is not appropriate because it is unnecessary and invasive. A femoral puncture is a procedure that involves inserting a needle into the femoral vein in the groin area to obtain a blood sample. It is usually reserved for situations where other veins are inaccessible or unsuitable, such as in trauma or shock. It is not indicated for a routine CBC test.

Choice B: Assist in holding the client's arm still. This action is not appropriate because it is harmful and contraindicated. Holding the client's arm still may cause injury or infection to the arm that has undergone surgery and lymph node removal. It may also increase the risk of lymphedema, which is a condition that causes swelling and pain in the arm due to fluid accumulation and impaired lymphatic drainage.

Choice C: Tell the technician to obtain the blood sample from the client's left arm. This action is appropriate because it is safe and recommended. Obtaining the blood sample from the client's left arm can avoid complications such as injury, infection, or lymphedema in the right arm that has undergone surgery and lymph node removal. The technician can use a different site than the antecubital space, such as the hand or wrist, to avoid interfering with the intravenous line.

Choice D: Suggest a finger stick be done on one of the client's left fingers. This action is not appropriate because it is unreliable and inaccurate. A finger stick is a procedure that involves pricking the finger with a lancet to obtain a small amount of blood for testing. It is usually used for point-of-care testing, such as glucose or hemoglobin levels, but not for a CBC test. A CBC test requires a larger volume of blood and a venous sample for accurate results.

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Correct Answer is B

Explanation

Choice A: "Don't worry, I will be with you during the exam." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound dismissive or patronizing to the client, who may have valid reasons to be nervous.

Choice B: "What part of the exam makes you most nervous?" This response is appropriate because it shows empathy and interest in the client's perspective. It also invites the client to express her fears or questions and allows the nurse to provide information and reassurance.

Choice C: "All you need to do is relax." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may find it hard to relax in a stressful situation.

Choice D: "A pelvic exam is required if you want birth control pills." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound coercive or threatening to the client, who may feel pressured or intimidated by the requirement.

A. Fecal incontinence B. Rectocele C. Urinary incontinence D. Cystocele E. Enterocele

Correct Answer is ["B","C","D","E"]

Explanation

Choice A: Fecal incontinence is not the correct answer because it is not a disorder of pelvic organ prolapse. Fecal incontinence is a condition that causes the loss of bowel control, resulting in involuntary leakage of stool or gas. It can be caused by various factors such as nerve damage, muscle weakness, or diarrhea. It is not related to the displacement or descent of pelvic organs.

Choice B: Rectocele is the correct answer because it is a disorder of pelvic organ prolapse. Rectocele is a condition that occurs when the rectum bulges or sags into the vagina, creating a pouch or hernia. It can cause symptoms such as constipation, difficulty with bowel movements, or a feeling of pressure or fullness in the vagina. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the rectum and vagina.

Choice C: Urinary incontinence is the correct answer because it is a disorder of pelvic organ prolapse. Urinary incontinence is a condition that causes the loss of bladder control, resulting in involuntary leakage of urine or urge to urinate. It can be caused by various factors such as stress, infection, or medication. It is also related to the displacement or descent of pelvic organs, such as the bladder or urethra, which can affect the function and closure of the urinary sphincter.

Choice D: Cystocele is the correct answer because it is a disorder of pelvic organ prolapse. Cystocele is a condition that occurs when the bladder protrudes or drops into the vagina, creating a pouch or hernia. It can cause symptoms such as urinary frequency, urgency, or retention, or a feeling of pressure or fullness in the vagina. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the bladder and vagina.

Choice E: Enterocele is the correct answer because it is a disorder of pelvic organ prolapse. Enterocele is a condition that occurs when the small intestine bulges or descends into the vagina, creating a pouch or hernia. It can cause symptoms such as lower back pain, pelvic pressure, or difficulty with bowel movements. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the small intestine and vagina.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reading a journal article about the care of a woman with pelvic organ prolapse. The nurse would expect to find information related to which disorder? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

A woman is admitted for repair of cystocele and rectocele. She has nine living children. In taking her health history, what would the nurse expect to find?

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available as hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing a class discussion on the clinical manifestations of a heart attack observed in women. Which symptoms would the nurse include as key assessment data? Select all that apply.

A nurse is preparing a class discussion on the clinical manifestations of a heart attack observed in women. Which symptoms would the nurse include as key assessment data? Select all that apply.

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients has a contraindication for receiving oral contraceptives.