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A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start performing monthly breast self-examinations at age 35.
- B. You should receive a breast examination from your provider each year after age 30.
- C. You should receive a breast ultrasound every 3 years after age 50.
- D. You should start receiving mammograms as early as age 40.
Correct Answer: D
Rationale: Mammograms starting at 40 align with standard screening guidelines for average-risk women.
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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Gloves ensure infection control. C: Side prick is correct technique. E: Iodine disinfects; A risks hemolysis, D impedes flow.
A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
- A. Temperature 37.5° C (99.5° F)
- B. Client is difficult to arouse.
- C. Respiratory rate 10/min
- D. Pulse oximetry 88% on room air
- E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg
- F. Heart rate 61/min
Correct Answer: B,C,D
Rationale:
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. My advance directives can be enforced once my attorney approves them.
- C. A family member will need to witness my signature on my living will.
- D. I can name my sibling as my designee in my durable power of attorney for health care.
Correct Answer: C
Rationale: A witness, often a family member, validates the living will, reflecting procedural understanding.