Nokea
A client states that she rates her pain as a 5 on a 0-10 scale post-mastectomy. The provider has ordered morphine 4 mg IV for moderate pain every 4 hours. The morphine is supplied as a solution of 8 mg/mL. How many mL will the nurse administer?
- A. 0.25 mL
- B. 0.5 mL
- C. 1 mL
- D. 2 mL
Correct Answer: B
Rationale: To calculate the dose: 4 mg (ordered) ÷ 8 mg/mL (concentration) = 0.5 mL. Thus, the nurse will administer 0.5 mL of morphine.
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After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)
- A. Peau d'orange
- B. Dense breast tissue
- C. Nipple retraction
- D. Mobile mass at two o'clock
- E. Non-tender axillary nodes
Correct Answer: A,C,D
Rationale: Peau d'orange (skin dimpling), nipple retraction, and a mobile mass at a specific location (e.g., two o'clock) are abnormal findings suggestive of breast cancer. Dense breast tissue and non-tender axillary nodes are not necessarily indicative of malignancy.
A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and another agent for breast cancer. What effect seen in the client should the nurse report to the provider immediately?
- A. Shortness of breath
- B. Hair loss
- C. Mucositis
- D. Vomiting
Correct Answer: A
Rationale: Doxorubicin (Adriamycin) can cause cardiac problems, with symptoms like shortness of breath indicating potential cardiotoxicity, which requires immediate reporting. Hair loss, mucositis, and vomiting are common chemotherapy side effects but are not immediately life-threatening.
A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate?
- A. Discourage this surgery since the woman is still of childbearing age.
- B. Reassure the client that reconstructive surgery is as easy as breast augmentation.
- C. Inform the client that this surgery removes all mammary tissue and cancer risk.
- D. Include support people, such as the male partner, in the decision making.
Correct Answer: D
Rationale: The cultural aspects of decision making need to be considered. In Nigerian culture, the man often plays a significant role in decision-making processes, so including support people like the male partner is appropriate to ensure culturally sensitive care.
The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.)
- A. Age greater than 65 years
- B. The elevated risk potential
- C. Osteoporosis
- D. Multiparity
- E. Genetic factors
Correct Answer: A,B,E
Rationale: Breast cancer risk factors include age greater than 65 (risk increases until age 80), increased breast density (elevated risk potential due to more glandular and connective tissue), and inherited mutations of BRCA1/BRCA2 genes. Osteoporosis and multiparity are not risk factors; high postmenopausal bone density and multiparity are moderate and low risk factors, respectively.
A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best?
- A. You do not need to worry about lymphedema since you did not have radiation therapy.
- B. A risk factor for lymphedema is infection, so wear gloves when gardening outside.
- C. Numbness, tingling, and swelling are common conditions after a mastectomy.
- D. The risk for lymphedema is a real threat and can be very self-limiting.
Correct Answer: B
Rationale: Infection can contribute to lymphedema, so wearing gloves during activities like gardening reduces this risk. Radiation is only one factor; others like obesity and axillary disease also contribute. Lymphedema symptoms are not common post-surgery, and while it is a concern, it is manageable with proper care.