Nokea
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Check the area after the next menstrual
- C. Squeeze the nipple to check for period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.
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Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term.
Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues.
Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels.
Step 4: Emergency numbers are important but secondary to long-term management.
Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.
Which of the following is a discharge criterion from the PACU for a patient following surgery?
- A. Oxygen saturation above 90%
- B. IV narcotics given less than 15 minutes ago
- C. Oxygen saturation below 90%
- D. IV narcotics given less than 30 minutes ago
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation above 90%. This is a discharge criterion because adequate oxygen saturation indicates the patient is breathing well and there is no immediate respiratory compromise. Oxygen saturation below 90% (choice C) would indicate hypoxemia and would not be safe for discharge. IV narcotics given less than 15 minutes ago (choice B) can still be in effect and may impair the patient's ability to function post-surgery. IV narcotics given less than 30 minutes ago (choice D) is a longer timeframe but still not ideal for discharge as the effects of the narcotics may not have fully worn off.
The physician orders furosemide (Lasix) 40 mg IV STAT for an acutely fluid-overloaded patient. Why was the IV route likely chosen?
- A. Furosemide can be administered only by the IV route.
- B. IV is the route of choice for rapid administration.
- C. IV dosing is more accurate.
- D. IV furosemide has a fewer side effects than oral.
Correct Answer: B
Rationale: The correct answer is B: IV is the route of choice for rapid administration. IV route allows for quick onset of action, crucial in acutely fluid-overloaded patients needing immediate diuresis. Option A is incorrect as furosemide can be given orally too. Option C is less relevant in this urgent situation where speed is key. Option D is also incorrect as the side effects are not determined by route of administration.
A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
- A. A rapid, thready pulse
- B. Decreased peristalsis .
- C. Respiratory congestion
- D. An increased in temperature
Correct Answer: A
Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia.
B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure.
C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern.
D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.
When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function.
Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.