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 D

Explanation

Choice A: Growth spurt is not the correct answer because it is not the first event that occurs in female puberty. The growth spurt is a period of rapid increase in height and weight that usually occurs between 10 and 14 years of age in girls. It is influenced by various factors such as genetics, nutrition, and hormones. Growth spurt usually follows the development of breast buds and pubic hair by about 6 to 12 months.

Choice B: Evidence of pubic hair is not the correct answer because it is not the first event that occurs in female puberty. Evidence of pubic hair is the appearance of coarse, curly, and pigmented hair on the pubic area and around the genitals. It usually occurs between 8 and 13 years of age in girls. It is caused by the increased production of androgens (male hormones) by the adrenal glands and ovaries. Evidence of pubic hair usually follows the development of breast buds by about 3 to 6 months.

Choice C: Onset of menses is not the correct answer because it is not the first event that occurs in female puberty. The onset of menses is the beginning of menstrual cycles, which are regular changes in the female reproductive system that prepare the body for pregnancy. It usually occurs between 10 and 15 years of age in girls. It is caused by the maturation of the hypothalamus, pituitary gland, ovaries, and uterus, which regulate the levels of estrogen and progesterone (female hormones). The onset of menses usually follows the development of breast buds and pubic hair by about 2 to 3 years.

Choice D: Development of breast buds is the correct answer because it is the first event that occurs in female puberty. Development of breast buds is the enlargement and elevation of the nipples and areolas (dark circles around the nipples), which indicate the beginning of breast growth. It usually occurs between 8 and 12 years of age in girls. It is caused by the increased production of estrogen (female hormone) by the ovaries, which stimulates the growth of ducts (tubes) and lobules (glands) in the breast tissue. The development of breast buds is also called thelarche or breast stage 2.

A. Sporadic vaginal bleeding accompanied by chronic pelvic pain B. Menstrual irregularities and hirsutism on the chin C. Heavy leukorrhea with vulvar pruritus D. Stress incontinence with feeling of low abdominal pressure

Correct Answer is D

Explanation

Choice A: Sporadic vaginal bleeding accompanied by chronic pelvic pain is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as endometriosis, fibroids, or cervical cancer.

Choice B: Menstrual irregularities and hirsutism on the chin are not the correct answers because they are not symptoms of cystocele or rectocele. These symptoms may indicate other conditions such as polycystic ovary syndrome (PCOS), thyroid disorder, or menopause.

Choice C: Heavy leukorrhea with vulvar pruritus is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as bacterial vaginosis, yeast infection, or sexually transmitted infection (STI).

Choice D: Stress incontinence with a feeling of low abdominal pressure is the correct answer because it is a symptom of cystocele or rectocele. Stress incontinence is a condition that causes leakage of urine when there is increased pressure on the bladder, such as during coughing, sneezing, laughing, or lifting. Cystocele or rectocele can cause stress incontinence by weakening the pelvic floor muscles and connective tissue that supports the bladder and urethra. The feeling of low abdominal pressure is also a symptom of cystocele or rectocele, as it indicates that the bladder or rectum is protruding into the vagina.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first?

Correct Answer is D

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?

Correct Answer is D

Explanation

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 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?

The public health nurse is teaching young adolescents in a sexual health class the proper use of a condom. Which statements made by the students indicate teaching was successful? 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 nurse is working with a woman who has been diagnosed with severe fibrocystic breast disease. After describing the medications that can be used as treatment, the nurse determines that additional teaching is needed when the client identifies which drug is being used.

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:

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?