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The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client
- A. Supine with arms at the side and a pillow under both knees
- B. Left lateral with the head resting on a pillow and the arm over the head
- C. Sitting forward with a pillow behind the shoulder blades with hands on the hips
- D. Supine, with the arm on the side raised behind the head, and a small pillow under the shoulder
Correct Answer: D
Rationale: Supine with the arm raised and a pillow under the shoulder flattens the breast tissue, facilitating palpation. Other positions are less effective for breast exams.
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The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.
The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up?
- A. Wheezes arise from the small airways and usually do not clear with coughing.
- B. A pleural friction rub causes loud, rough, scratching sounds usually during inspiration.
- C. Thick, tenacious secretions that clear with coughing cause crackles.
- D. Fluid or secretions in large airways typically cause coarse crackles.
Correct Answer: C
Rationale: Crackles are caused by air moving through fluid in small airways and do not typically clear with coughing. Other statements are accurate.
The nurse recognizes which of the following treatments are alternative treatments for anxiety. Select all that apply.
- A. Black cohosh
- B. Ginger
- C. St. John's wort
- D. Kava
- E. Passion flower
Correct Answer: D,E
Rationale: Kava and passion flower are used for anxiety relief. Black cohosh treats menopausal symptoms, ginger aids nausea, and St. John’s wort is for depression.