An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Voiding after intercourse to reduce infection.

Need for scheduling annual well woman exams.

The importance of using vaginal lubricants.

Intercourse positions that can help prevent tears.

Answer and Explanation

The Correct Answer is C

A.   While voiding after intercourse can help reduce the risk of urinary tract infections (UTIs), it is not directly related to preventing vaginal tears. This practice is more relevant for preventing infections rather than addressing the issue of tissue trauma or dryness that may lead to tearing.
B.   Regular well-woman exams are important for overall gynecological health and early detection of potential issues, but they do not directly address the immediate concern of preventing vaginal tears during intercourse.
C.   Vaginal dryness is a common issue in older women, often due to decreased estrogen levels. Dryness can make vaginal tissues more susceptible to tearing during intercourse. Using vaginal lubricants can help reduce friction and prevent tears, making this the most relevant and practical advice for the client in this situation.
D.   While certain positions may be more comfortable and could potentially reduce the risk of tearing, this advice is secondary to addressing the fundamental issue of vaginal dryness. Focusing on lubrication provides a more direct and effective approach to preventing tears.

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Correct Answer is A

Explanation

A. It's normal for the reservoir bag not to deflate completely during inspiration. A respiratory rate of 14 breaths/minute is within the normal range (12-20 breaths/minute). If the client is comfortable and their oxygen saturation is within the normal range, there is no need for intervention. Documenting the assessment data for future reference is sufficient.
B. Increasing the liter flow of oxygen may not be necessary if the client's oxygen saturation is within the normal range. It could also lead to oxygen toxicity if the flow is set too high.
C. Encouraging deep breaths may not be necessary if the client's respiratory rate is within the normal range.
D. Removing the mask to deflate the bag is not necessary and could interfere with the delivery of oxygen.

A. The consistency of the prescribed diet. B. Review of current medications. C. Client's ability to chew and swallow. D. The client's respiratory rate and lung sounds.

Correct Answer is C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

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An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?