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A nurse is assisting with an education program about breast self-examinations. Which of the following information should the nurse include?
- A. Perform breast self-examinations 1 week following menses.
- B. Palpate the breasts using a left to right motion.
- C. Express discharge from the nipple each month.
- D. Avoid performing breast self-examinations while showering.
Correct Answer: A
Rationale: The correct answer is A: Perform breast self-examinations 1 week following menses. This timing is ideal because breasts are less likely to be tender or swollen during this time, making it easier to detect any abnormalities. Performing the exam at the same time each month helps in noticing changes. Option B is incorrect because the recommended motion is in a circular pattern. Option C is incorrect because expressing discharge is not a part of breast self-examination. Option D is incorrect as performing the exam in the shower is actually beneficial due to the slippery nature of wet skin, aiding in smooth palpation.
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A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Poor skin turgor
- B. Bradycardia
- C. Hypotension
- D. Pale yellow urine
- E. Flat neck veins
Correct Answer: A,C,E
Rationale: Poor skin turgor, hypotension, and flat neck veins indicate dehydration due to fluid loss. Bradycardia is incorrect; tachycardia is expected. Pale yellow urine suggests adequate hydration.
A nurse is caring for a client who has not voided for 8 hr following surgery. Which of the following actions should the nurse take first?
- A. Offer the client fluids.
- B. Perform a bladder scan.
- C. Insert an indwelling urinary catheter.
- D. Provide assistance to bathroom.
Correct Answer: B
Rationale: The correct answer is B: Perform a bladder scan. This is the first action the nurse should take because it provides valuable information about the client's bladder status without invasive intervention. The bladder scan will help determine if the client has urinary retention, which could be the reason for not voiding after surgery. Offering fluids (choice A) is important but should come after assessing the bladder. Inserting a urinary catheter (choice C) is invasive and should only be done if necessary. Providing assistance to the bathroom (choice D) is not appropriate if there is a possibility of urinary retention.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
- A. Erythema
- B. Pallor
- C. Coolness
- D. Drainage
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice B) and coolness (choice C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop the coordination and balance needed to ride a tricycle around the age of 3. This activity helps improve gross motor skills and coordination. Jumping rope (A) requires more advanced motor skills and coordination. Printing letters and numbers (C) involves fine motor skills that develop later. Using scissors to cut out a picture (D) also requires more advanced fine motor skills and hand-eye coordination.