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 C

Explanation

Choice A: Limit the intake of fluid. This action is not correct and should not be taught to the client. Limiting the intake of fluid can cause dehydration, urinary tract infection, or kidney stones. The client should drink enough fluid to keep her urine clear and odorless.

Choice B: Void every hour while awake. This action is not correct and should not be taught to the client. Voiding every hour while awake can cause bladder irritation, infection, or overdistension. The client should void when she feels the urge or at least every 3 to 4 hours.

Choice C: Perform Kegel exercises daily. This action is correct and should be taught to the client. Kegel exercises are exercises that strengthen the pelvic floor muscles that support the bladder and urethra. They can help improve bladder control and prevent urinary incontinence. The client should perform Kegel exercises daily by contracting and relaxing the muscles around the vagina and anus as if she is trying to stop urinating or passing gas.

Choice D: Take a laxative every night. This action is not correct and should not be taught to the client. Taking a laxative every night can cause diarrhea, dehydration, electrolyte imbalance, or dependence. The client should avoid constipation by eating a high-fiber diet, drinking plenty of fluids, and exercising regularly.

A. Trichomoniasis B. Genital herpes simplex C. Candidiasis D. Bacterial vaginosis

Correct Answer is C

Explanation

Choice A: Trichomoniasis is not the correct answer because it does not match the findings of the client. Trichomoniasis is a sexually transmitted infection (STI) caused by a parasite called Trichomonas vaginalis. It can cause symptoms such as yellow-green or gray frothy vaginal discharge, foul odor, itching, burning, or redness of the vulva or vagina.

Choice B: Genital herpes simplex is not the correct answer because it does not match the findings of the client. Genital herpes simplex is an STI caused by a virus called herpes simplex virus (HSV). It can cause symptoms such as painful blisters or ulcers on or around the genitals, fever, headache, or swollen lymph nodes.

Choice C: Candidiasis is the correct answer because it matches the findings of the client. Candidiasis is a fungal infection caused by a yeast called Candida albicans. It can cause symptoms such as thick, white, cottage cheese-like vaginal discharge, intense itching, burning, or soreness of the vulva or vagina, or dyspareunia (painful sexual intercourse).

Choice D: Bacterial vaginosis is not the correct answer because it does not match the findings of the client. Bacterial vaginosis is a condition caused by an imbalance of the normal vaginal flora (the bacteria that live in the vagina). It can cause symptoms such as thin, gray-white or yellow vaginal discharge, fishy odor, itching, or burning of the vulva or vagina.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assist the woman in regaining control of the urinary sphincter after bladder surgery, the nurse should teach the client to perform which action?

Correct Answer is C

Explanation

Assessment of a female client reveals a thick, white vaginal discharge. She also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has:

Correct Answer is C

Explanation

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 client for radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?

A nurse is caring for a client who is one day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:

Which factors are the main causes of the high infant mortality rate? Select all that apply.

A nurse is assessing a male client recently diagnosed with genital herpes. Which finding would most likely correlate with this diagnosis?

A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?

Which finding would the nurse expect in a client with bacterial vaginosis?