Nokea
The nurse is assessing a 34-year-old female client with fibrocystic breasts. Which question should the nurse ask the client during the assessment?
- A. Are your breasts more tender during your period?'
- B. Have you ever developed an allergy to chocolate?'
- C. Can you tell me more about your feelings of having fibrocystic breast changes?'
- D. Have you considered having a prophylactic mastectomy?'
Correct Answer: A
Rationale: Fibrocystic breast changes cause cyclical tenderness, worse premenstrually; this question assesses symptoms. Chocolate allergies, feelings, and prophylactic mastectomy are irrelevant.
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The charge nurse is making rounds on the genitourinary surgery floor. Which action by the primary nurse warrants immediate intervention?
- A. The nurse elevates the scrotum of a client who has had an orchiectomy.
- B. The nurse encourages the client to cough, although he complains of pain.
- C. The nurse empties the client’s JP drain and leaves it rounded.
- D. The nurse asks the UAP to empty a catheter drainage bag.
Correct Answer: B
Rationale: Encouraging coughing despite pain risks complications (e.g., bleeding) post-surgery; pain control is needed first. Scrotal elevation, JP drain management, and UAP delegation are appropriate.
If a culture is ordered to detect the causative organism, which body substance will the nurse collect?
- A. Venous blood
- B. Sterile urine
- C. Specialized semen
- D. Urethral drainage
Correct Answer: D
Rationale: Urethral drainage is the primary specimen for culturing gonorrhea, as it directly samples the infection site.
Before taking the client to the room where the pelvic examination will be performed, which nursing action is most appropriate?
- A. Ask the client to sign a consent form.
- B. Give the client a gown to wear.
- C. Offer the client a mild analgesic.
- D. Help the client instill a vaginal lubricant.
Correct Answer: B
Rationale: Providing a gown ensures the client's privacy and comfort during the pelvic examination, which is a priority before the procedure.
The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group?
- A. The clients should find out about their family history of breast cancer.
- B. Men at this age can get breast cancer also and should be screened.
- C. Monthly breast self-examination is the key to early detection.
- D. The older a woman gets, the greater the chance of developing breast cancer.
Correct Answer: D
Rationale: Age is the most significant risk factor for breast cancer, with risk increasing as women age, especially in seniors. Family history is important but less universal, male breast cancer is rare, and BSE is secondary to awareness and screening.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP?
- A. Increase the drip rate on the Murphy drip irrigation set.
- B. Check the suprapubic catheter insertion site for infection.
- C. Encourage the two (2)-hour postoperative client to turn and cough.
- D. Document the amount of red drainage in the catheter.
Correct Answer: C
Rationale: Encouraging turning and coughing is within UAP scope to prevent respiratory complications. Adjusting irrigation, checking for infection, and documenting drainage require nursing judgment.