Nokea
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?
- A. Perform breast self-examinations during the middle of your cycle.
- B. Perform breast self-examinations while lying on your side.
- C. Use small, circular motions, working vertically up and down across the breast.
- D. Use the palm of your hand to detect the presence of any large masses under the skin.
Correct Answer: C
Rationale: Using small, circular motions in a vertical pattern is the correct technique for breast self-examination, making this an appropriate statement.
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A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Clamp the tube for 30 min every 8 hr.
- B. Pin the tubing to the client's bed sheets.
- C. Monitor for at least 150 mL of drainage every hour.
- D. Replace the unit when the drainage chamber is full.
Correct Answer: D
Rationale: Replacing the unit when the drainage chamber is full ensures proper function and prevents complications, such as obstruction or infection, in a closed-chest tube system.
A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?
- A. Testicular
- B. Skin
- C. Prostate
- D. Colorectal
Correct Answer: A
Rationale: Testicular self-examination is recommended for young males (e.g., 18-year-olds) to detect early signs of testicular cancer.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
- A. Do you have any pain this morning?
- B. Is your pain the same as it has been?
- C. Could you rate your pain on a scale from 0 to 10?
- D. What does your pain feel like?
Correct Answer: D
Rationale: Asking 'What does your pain feel like?' assesses the quality (e.g., sharp, dull), a key component of pain assessment.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses.
Day 3, 2300:
Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.
The nurse is reviewing the client's electronic medical record (EMR). Select statements in the EMR that indicate the client's condition is improving since implementing interventions.
- A. Temperature 37.8°C (100°F)
- B. Client is alert and oriented to person, place, and time
- C. Bilateral breath sounds clear and present throughout
- D. Feet warm with intact movement and sensation
- E. Heart rate 98/min
- F. Bilateral pedal pulses 3+
- G. Respiratory rate 20/min
Correct Answer: B,C,D
Rationale: Alertness, clear breath sounds, and warm feet with intact sensation indicate recovery from the initial injury and fasciotomy.