NURS 131 Reproductive Study Notes

jasmine's version from 2016-05-04 02:05


Question Answer
You are assessing a long-term care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? The bladder is palpable above the symphysis pubis and the client is restless. Rationale: A palpable bladder and restlessness are indicators of bladder distention, which would require action (such as insertion of a catheter) in order to empty the bladder (Focus: Prioritization)
While performing a breast examination on a 22 year old client, you obtain the following data. Which finding is of most concern? An irregularly shaped, non-tender lump is palpable in the left breast. Rationale: Irregularly shaped and non-tender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound (Focus: Prioritization)
After undergoing a modified radical mastectomy, a client is transferred to the post-anesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/LVN? Monitoring the client’s dressing for any signs of bleeding. Rational: An LPN/LVN working in a PACU would be expected to check dressings for bleeding and alert RN staff members if bleeding occurred
You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? Elevating the client’s arm on two pillows to promote lymphatic drainage (Focus: Delegation)
You obtain the following assessment data about your client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? The client reports painful bladder spasms. Rational: The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 – 50 mL of saline using a piston syringe (Focus: Prioritization)
A 67 year old client with BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client? “You should avoid sitting up or standing up too quickly.” Rational: Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness (Focus: Prioritization)
You are caring for a client who has just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? Catheter that is draining deep red blood. Rational: Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately (Focus: Prioritization)