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A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. The best time to perform a breast self-examination is on the first day of my period.
- B. I can expect to have regular periods until I am in menopause.
- C. I might have headaches due to a decline in my estrogen levels.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: C
Rationale: Declining estrogen levels during perimenopause can cause headaches.
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A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Use a filter needle to aspirate the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Cleanse the tip of the ampule with an alcohol swab after opening.
- D. Add 0.5 mL of diluent to the medication.
Correct Answer: A
Rationale: A filter needle prevents glass particles from entering the syringe.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Repeat the test three times using the same stool specimen.
- B. Wear sterile gloves when handling the stool specimen.
- C. Have the client defecate into a bedpan that contains a small amount of water.
- D. Ensure that the stool specimen does not contain urine.
Correct Answer: D
Rationale: Ensuring no urine contamination maintains specimen integrity for accurate testing.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Occupational therapist
- B. Registered dietitian
- C. Respiratory therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: A speech-language pathologist is specifically trained to evaluate and treat swallowing disorders (dysphagia), which makes them the appropriate specialist for this referral.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.