Nokea
A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. A nonmobile mass with irregular edges
- C. A mobile mass that is soft and easily delineated
- D. Nonpalpable right axillary lymph nodes
Correct Answer: B
Rationale: A nonmobile mass with irregular edges would most strongly suggest that the patient's lump is cancerous. Breast cancer lumps typically do not move easily and have irregular, poorly defined edges. These characteristics are concerning because they can indicate an invasive and aggressive growth pattern. Additionally, the fact that the lump is painless is another feature that raises suspicion for malignancy. It is important for the patient to undergo further evaluation, possibly including a mammogram, ultrasound, and biopsy, to determine the nature of the lump and provide appropriate treatment.
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The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
- A. A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away.
- B. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
- C. A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away.
- D. A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
Correct Answer: A
Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.
The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)
- A. Keeping the urine collection container on ice when indicated
- B. Withholding all patient medications for the day
- C. Irrigating the sample as needed with sterile solution
- D. Testing the urine sample with a reagent strip by dipping it in the urine
Correct Answer: A
Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.
A nurse is asked how many kcal per gram fats provided. How should the nurse answer?
- A. 3
- B. 4
- C. 6
- D. 9
Correct Answer: D
Rationale: Fats, also known as lipids, are the most calorie-dense nutrient, providing 9 kcal per gram. This high calorie content is due to the structure of fats, which contain more carbon-hydrogen bonds, making them more energy-dense compared to carbohydrates and proteins. Carbohydrates and proteins, on the other hand, provide 4 kcal per gram each. This makes fats an important source of energy in the diet, but they should be consumed in moderation to maintain a healthy balance of nutrients.
For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to
- A. 6:30 AM on January 13
- B. 6:30 PM on January 13
- C. 6:30 PM on January 14
- D. 6:30 AM on January 15
Correct Answer: A
Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.
A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?
- A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
- B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
- C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
- D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B
Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.