Nokea
A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?
- A. Multiple firm, round, freely movable masses.
- B. A slight asymmetry of the breasts.
- C. A fixed nodular mass with dimpling of the skin.
- D. Bloody discharge from the nipple.
Correct Answer: C
Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.
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A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?
- A. Flush the tube with water every 4 hours
- B. Check the tube placement before each feeding
- C. Secure the tube to the client's nose with tape
- D. Keep the head of the bed elevated at 30 degrees
Correct Answer: B
Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.
The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct Answer: B
Rationale: Correct! In right-sided congestive heart failure, jugular vein distention is a common finding due to the backup of blood in the systemic circulation. This results in increased venous pressure, leading to jugular vein distention. Choices A, C, and D are incorrect because decreased urinary output, pleural effusion, and bibasilar crackles are more commonly associated with other conditions such as kidney dysfunction, lung issues, and pulmonary edema.
After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. Client with pneumonia who has a fever of 101.5°F
- B. Client who underwent knee surgery and needs dressing change
- C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
- D. Client with diabetes requesting insulin
Correct Answer: C
Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.
A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?
- A. Administer antiemetic medication as prescribed.
- B. Monitor the client's intake and output.
- C. Provide mouth care to keep the client comfortable.
- D. Elevate the client's head of the bed.
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.