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A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
- A. Using the palm of the hand, feel for lumps using a circular motion.
- B. Expect some breast dimpling or discharge with age.
- C. Breasts can be examined in the shower with soapy hands.
- D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
Correct Answer: C
Rationale: The correct answer is C: Breasts can be examined in the shower with soapy hands. This instruction is important because warm water and soap help to make the examination more comfortable and easier to detect any abnormalities. By examining the breasts in the shower, the individual can incorporate BSE into their routine without it feeling like a separate task. This method also allows for better coverage and thorough examination of the entire breast tissue.
Choice A is incorrect because using the palm of the hand in a circular motion may not be as effective in detecting lumps compared to using the fingertips. Choice B is incorrect as breast dimpling or discharge are not normal signs of aging, and should be reported to a healthcare provider. Choice D is incorrect as performing BSE at specific times in the menstrual cycle is not necessary.
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A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
- A. Take the medication with orange juice.
- B. Take the medication between meals.
- C. Take the medication on an empty stomach.
- D. Take the medication with milk.
Correct Answer: D
Rationale: The correct answer is D: Take the medication with milk. Betamethasone can cause stomach irritation, so taking it with milk can help reduce this side effect. Milk coats the stomach lining, providing a protective barrier. This helps to minimize the risk of gastrointestinal upset.
A: Taking the medication with orange juice is not recommended as it can increase stomach irritation due to its acidity.
B: Taking the medication between meals may not provide the same protective effect on the stomach lining as taking it with milk.
C: Taking the medication on an empty stomach can increase the risk of gastrointestinal irritation and should be avoided.
E, F, G: These options are not relevant to the administration of betamethasone.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
- A. 730
- B. 745
- C. 815
- D. 720
Correct Answer: A
Rationale: The correct answer is A: 730. After administering regular insulin, it is crucial to ensure the client receives breakfast within 30 minutes to an hour to prevent hypoglycemia. Breakfast at 730 allows adequate time for the insulin to start working before the client consumes food. Choice B (745) is too late, increasing the risk of hypoglycemia. Choice C (815) is too delayed and may cause an imbalance in blood sugar levels. Choice D (720) is too soon after administering insulin, increasing the risk of hypoglycemia.
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.