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

The importance of using vaginal lubricants.

Intercourse positions that can help prevent tears.

Information about alternative ways to express sexuality.

Methods used to practice safe sex.

Answer and Explanation

The Correct Answer is A

Choice A reason: Vaginal lubricants are critical to prevent tears in older adults, as postmenopausal estrogen decline reduces vaginal lubrication and elasticity, increasing tissue fragility. Lubricants reduce friction during intercourse, minimizing mucosal injury, which risks infection. This directly addresses the cause of the tear, promoting healing and preventing recurrence, making it the priority teaching.

Choice B reason: Intercourse positions may reduce strain but do not address the primary cause of vaginal tears: dryness from low estrogen. Lubricants directly hydrate tissue, reducing tear risk. Positions are secondary, as they don’t restore mucosal integrity, which is critical for preventing further trauma, making this less important than lubricant education.

Choice C reason: Alternative ways to express sexuality (e.g., non-penetrative intimacy) are valid but not the most urgent. Vaginal tears result from dryness, which lubricants address by reducing friction. Alternative expressions don’t prevent physical injury during intercourse, the client’s concern, making this less critical than teaching lubricant use for tissue protection.

Choice D reason: Safe sex methods (e.g., condoms) prevent infections but do not address vaginal tears caused by dryness. While important, especially for unprotected intercourse, the tear’s etiology is postmenopausal tissue fragility. Lubricants prevent further mechanical trauma, prioritizing tissue health over infection prevention in this context, making this secondary.

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Correct Answer is D

Explanation

Choice A reason: Bending at the waist to hang a urinary unit risks back injury, as it violates body mechanics. Standing erect with bent knees uses leg muscles, reducing strain. This incorrect posture increases musculoskeletal injury risk, per ergonomic and safe patient handling guidelines in nursing.

Choice B reason: Stretching over the mattress to pick up an item strains the back and shoulders, ignoring body mechanics. Standing erect with bent knees ensures safe movement. This action risks injury, contradicting ergonomic principles, per safe patient handling and occupational safety standards in healthcare.

Choice C reason: Pushing a drawer closed with the hip avoids proper body mechanics, risking strain or injury. Standing erect with bent knees during client movement is safer. This action is unrelated to client care safety, per ergonomic and safe handling protocols in nursing practice.

Choice D reason: Standing erect with knees bent to pull a draw sheet uses proper body mechanics, leveraging leg muscles to reduce back strain. This minimizes injury risk during client movement, aligning with safe patient handling and ergonomic principles, per occupational safety and nursing care standards.

A. Measure oxygen saturation. B. Determine pulse pressure. C. Auscultate heart sounds. D. Check for jugular vein distension.

Correct Answer is A

Explanation

Choice A reason: Accessory neck muscle use indicates respiratory distress, likely from airway obstruction or lung disease, reducing oxygen delivery. Measuring oxygen saturation via pulse oximetry quantifies hypoxemia, critical for assessing alveolar gas exchange. Low saturation prompts immediate oxygen therapy, addressing the primary physiological threat of tissue hypoxia, making this the first action.

Choice B reason: Determining pulse pressure (systolic minus diastolic) assesses cardiovascular status but is less urgent than oxygen saturation. Accessory muscle use suggests respiratory compromise, impairing alveolar ventilation, not primarily a cardiac issue. Hypoxemia affects oxygen transport, requiring saturation measurement to guide intervention, making pulse pressure a secondary assessment.

Choice C reason: Auscultating heart sounds evaluates cardiac function but does not address respiratory distress. Accessory muscle use reflects increased respiratory effort, likely from hypoxia, affecting pulmonary gas exchange. Oxygen saturation directly measures oxygenation, guiding urgent therapy, while heart sounds are secondary unless cardiac failure is suspected, making this less immediate.

Choice D reason: Checking jugular vein distension assesses fluid overload, potentially linked to heart failure, but is not immediately relevant. Accessory muscle use primarily indicates respiratory distress, requiring oxygen saturation to confirm hypoxemia. Jugular distension is a supportive finding, but saturation measurement prioritizes addressing the acute oxygenation deficit, making it critical.

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Naxlex Comprehensive Predictor Exams

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Correct Answer is D

Explanation

While measuring vital signs, the nurse observes a client using accessory neck muscles during respiration. Which follow-up action should the nurse take first?

Correct Answer is A

Explanation

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because “shots hurt.” Which action should the nurse take?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client’s axilla. Which action should the nurse take?

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

A client requests heat therapy for lower back pain. Which action should the nurse take?

A client’s spouse has just learned of the client’s terminal illness. The spouse is sitting in the corner of the client’s room crying and says to the nurse, “I feel as if I’m already so alone.” Which action should the nurse take first?

When entering a client’s room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?