While working on the hospital surgical unit, you are assigned to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which task included in this client's care can you delegate to a nursing assistant?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Elevate the client's arm on two pillows to promote lymphatic drainage, which can be delegated to a nursing assistant. This task is appropriate for delegation because it is a non-invasive intervention that does not require specialized knowledge or assessment skills. Nursing assistants are trained to assist with activities of daily living and basic patient care, like positioning clients for comfort. Option A) Teach the client why blood pressure measurements are taken on the left arm requires specialized knowledge and explanation that should be provided by a nurse. Option C) Assess the client's right arm for lymphedema involves a comprehensive assessment that requires nursing judgment and skill, so it should not be delegated. Option D) Wrap the client's right arm with elastic bandages involves applying a treatment that requires assessment, judgment, and knowledge of proper technique, making it inappropriate for delegation to a nursing assistant. In an educational context, understanding the principles of delegation is crucial for nursing students and healthcare professionals to ensure safe and effective patient care. Delegation involves assigning appropriate tasks to the right personnel based on their competency level, training, and scope of practice. It is important to differentiate between tasks that can be delegated and those that require specialized skills to maintain patient safety and quality of care.

Correct Answer: A

Rationale: The correct answer is A) The nurse observes the client for any discomfort in the shoulders. In a culdoscopy, the procedure involves examining the reproductive organs through the vaginal wall. Shoulder pain post-culdoscopy can be indicative of peritoneal irritation due to the introduction of gas into the abdominal cavity during the procedure. This referred pain to the shoulders is a common side effect and the nurse needs to monitor for it. Option B is incorrect because while monitoring for signs of internal bleeding and shock is important in any post-procedure care, it is not specifically related to culdoscopy. Option C is incorrect as changes in skin color and body temperature are not typical indicators of complications post-culdoscopy. Option D is incorrect as urinary output monitoring is not directly relevant to a culdoscopy procedure. Educationally, understanding the specific post-procedure care for various examinations is crucial for nurses to provide effective and safe patient care. By knowing the expected outcomes and potential complications of procedures like culdoscopy, nurses can intervene promptly and ensure optimal patient outcomes.

Correct Answer: C

Rationale: Regular gynecologic examinations and Pap tests are essential for women's health for several reasons. The correct answer, C, is that it increases the potential for an early diagnosis. Regular screenings can detect any abnormalities or signs of diseases like cervical cancer early, allowing for timely intervention and treatment, which significantly improves outcomes and survival rates. Option A, deciding the mode of surgical treatment, is incorrect because gynecologic examinations and Pap tests are diagnostic procedures and not directly related to deciding surgical treatments. Option B, being the best cure for most infections, is incorrect because while Pap tests can detect infections like HPV, they are primarily aimed at identifying precancerous or cancerous changes in the cervix, not for curing infections. Option D, stating that it is an inexpensive test, is incorrect because while Pap tests are generally affordable, the primary reason for recommending them is for early detection and prevention of serious health issues rather than cost-effectiveness. In an educational context, nurses play a crucial role in promoting women's health through patient education. By explaining the importance of regular gynecologic examinations and Pap tests, nurses empower women to take charge of their health and well-being, leading to early detection of potential health concerns and ultimately improving health outcomes. This education emphasizes the preventive aspect of healthcare, encouraging women to prioritize screenings for early intervention and better health management.

Correct Answer: C

Rationale: In the case of a client undergoing antibiotic treatment for epididymitis and orchitis, it is crucial for nursing interventions to be appropriate and effective. Elevating the scrotum to relieve pain is the correct answer (Option C) because it helps reduce swelling and discomfort by promoting better blood flow and reducing pressure on the affected area. This intervention aids in the overall management of the conditions and can contribute to the client's comfort and recovery. Option A, using an alcohol rub to keep the scrotum dry, is incorrect because alcohol can cause irritation and dryness to the skin, potentially worsening the condition. Option B, applying a skin cream, is also inappropriate as it may not address the underlying infection and could potentially introduce unwanted substances to the sensitive area, leading to further complications. Option D, limiting alcohol intake to 2 drinks per week, is unrelated to the management of epididymitis and orchitis. While reducing alcohol consumption can generally benefit health, it is not a specific nursing intervention for these conditions. Educationally, understanding the rationale behind nursing interventions in reproductive system conditions is vital for providing safe and effective care. Nurses need to be aware of appropriate measures to alleviate symptoms and support the healing process in such cases to ensure positive outcomes for their clients.

Correct Answer: A

Rationale: The correct answer is A) Have an annual Papanicolaou smear to detect cervical cancer. This instruction is appropriate for a client undergoing treatment for an HSV-2 infection because HSV-2 is a sexually transmitted infection that can increase the risk of cervical cancer due to its association with human papillomavirus (HPV). Regular Pap smears are essential for early detection and treatment of cervical cancer in women with HSV-2. Option B) Have an annual mammogram to detect breast cancer is incorrect because HSV-2 does not directly increase the risk of breast cancer, so routine mammograms are not specifically indicated for this client. Option C) Increase the frequency of breast self-examination for early detection of any breast disorders is also incorrect as HSV-2 does not impact breast health, and breast self-exams are not relevant in this context. Option D) Undergo an HIV detection test every six months is incorrect as HSV-2 and HIV are separate infections, and having HSV-2 does not necessitate more frequent HIV testing unless there are specific risk factors present. In an educational context, it is crucial for nurses to provide accurate and relevant instructions to clients based on their specific health conditions. Understanding the associations between different infections and cancers helps nurses tailor their education to promote optimal health outcomes for their clients. Regular screenings and preventive measures are essential in managing the health of individuals with HSV-2 and reducing their risks of associated complications.