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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A: Protrusion of the posterior bladder wall downward through the anterior vaginal wall is not the correct answer because it describes a different condition called cystocele. A cystocele occurs when the bladder pushes into the vagina due to weakened pelvic support structures.

Choice B: Bulging of the small intestine through the posterior vaginal wall is the correct answer because it describes an enterocele. Enterocele occurs when the small intestine slides into a pouch between the rectum and vagina due to weakened pelvic support structures.

Choice C: Descent of the uterus through the pelvic floor into the vagina is not the correct answer because it describes a different condition called uterine prolapse. Uterine prolapse occurs when the uterus drops down into or out of the vagina due to weakened pelvic support structures.

Choice D: Sagging of the rectum with the pressure exerted against the posterior vaginal wall is not the correct answer because it describes a different condition called rectocele. Rectocele occurs when the rectum bulges into or out of the vagina due to weakened pelvic support structures.

A. Limit the intake of fluid. B. Void every hour while awake. C. Perform Kegel exercises daily. D. Take a laxative every night.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with an enterocele. The nurse interprets this condition as:

Correct Answer is B

Explanation

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

A nurse reading a journal article about the care of a woman with pelvic organ prolapse would expect to find information on which disorder. Select all that apply.

A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?

A client who has come to the clinic is diagnosed with endometriosis. What would the nurse expect the primary care provider to prescribe as a first-line treatment?

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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?

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.