Nokea
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams the day my period begins.
- B. I will perform breast exams every other month.
- C. It is common for the skin on my breasts to dimple.
- D. It is common for one breast to be larger than the other.
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.
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A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
- A. I can have clear liquids up to 3 hours before the procedure.
- B. I can eat as soon as the procedure is completed.
- C. I will receive an injection of radioactive material prior to having the procedure.
- D. I might have blood-tinged sputum after the procedure.
Correct Answer: D
Rationale: Blood-tinged sputum is normal post-bronchoscopy due to airway irritation, showing understanding. Clear liquids stop earlier, eating waits until gag reflex returns, and no radiation is involved.