Nokea
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection.
2. Mammograms are most effective for women aged 40 and older in detecting breast cancer.
3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes.
Summary of why other choices are incorrect:
B: Mammograms should start at age 40, not after the birth of the first child.
C: Mammograms are not recommended after the first menstrual period; they should start at age 40.
D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.
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Before administering a food feeding the nurse knows to perform which of the following assessments/
- A. The GI tract, including bowel sounds, last BM, and distention
- B. The client’s neurologic status, especially the gag reflex
- C. The amount of air in the stomach
- D. That the formula is used directly from the refrigerator
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
- A. Administer oxygen therapy
- B. provide frequent linen changes
- C. provide fluid intake 3L/day
- D. maintain complete bed rest
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.
Which of the following nursing interventions is correctly categorized as collaborative?
- A. Administering medications as prescribed by the healthcare provider
- B. Ordering a low-sodium diet for a hypertensive client
- C. Providing health education about medication side effects
- D. Monitoring a client’s response to an intervention initiated by another healthcare professional
Correct Answer: D
Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively.
A: Administering medications is typically an independent nursing intervention.
B: Ordering a low-sodium diet is within the scope of a nurse's independent practice.
C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members.
In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
- A. Naturally acquired active immunization
- B. Artificially acquired passive
- C. Artificially acquired active immunization immunization
- D. Passive immunization
Correct Answer: D
Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system.
- A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection.
- B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection.
- C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.