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A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C. Oral contraceptives have been associated with an increased risk of breast cancer due to the hormonal changes they induce in the body. Estrogen and progesterone in oral contraceptives can promote the growth of breast cells, potentially leading to cancer. Daily caffeine consumption (A) and a history of seasonal allergies (B) are not directly linked to breast cancer development. Routine use of multivitamins (D) is generally considered beneficial for overall health and does not increase breast cancer risk.
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Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes, prolonged high blood sugar levels can damage small blood vessels in the retina, leading to retinopathy, a microvascular complication affecting the eyes. This can result in vision problems or even blindness. Peripheral neuropathy (A) is a macrovascular complication affecting the nerves, not the microvasculature. Hypertension (B) is a common comorbidity but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving large blood vessels in the brain, not microvasculature. Thus, the nurse should identify retinopathy (C) as the correct indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
- A. Edema at the site
- B. Severe pain at the site
- C. Epithelialization at the site
- D. Blistering at the site
Correct Answer: A
Rationale: The correct answer is A: Edema at the site. After sustaining major full-thickness burns, the body initiates an inflammatory response, leading to increased capillary permeability and fluid accumulation in the interstitial space, causing edema. This is a normal physiological response to burns. Edema helps in the healing process by providing nutrients and oxygen to the damaged tissues. Choices B, C, and D are incorrect. Severe pain may not be present initially due to nerve damage from the burn. Epithelialization typically occurs during the later stages of burn healing. Blistering is more commonly seen in partial-thickness burns rather than full-thickness burns.