Nokea
The nurse is talking with a client who has breast cancer and is receiving tamoxifen. Which of the following statements by the client would require immediate follow-up?
- A. I have been experiencing frequent hot flashes
- B. I have been experiencing vaginal dryness
- C. I have had a decreased interest in sexual intercourse
- D. I have noticed that my menses are heavy
Correct Answer: D
Rationale: Heavy menses while on tamoxifen may indicate endometrial hyperplasia or cancer, a serious side effect requiring immediate evaluation. Hot flashes, vaginal dryness, and decreased libido are common, less urgent side effects.
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The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.
The nurse is suctioning an adult's tracheostomy tube. What action is essential before starting to suction the client?
- A. Have the client drink a glass of water to liquefy secretions
- B. Administer high levels of oxygen to the client
- C. Have the client sign a permit for suctioning
- D. Give the client a pad of paper and a pencil so he can communicate while the nurse suctions
Correct Answer: B
Rationale: Pre-oxygenation with high oxygen levels prevents hypoxia during tracheostomy suctioning, critical for patient safety, unlike water, consents, or communication aids.
The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?
- A. I can expect the cord to turn black in a few days
- B. I should let the cord fall off by itself
- C. I’ll give my newborn sponge baths until the cord falls off
- D. I’ll secure the diaper over the cord to protect it
Correct Answer: D
Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.
A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.