Nokea
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
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The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
- A. When the temperature rises above 101F
- B. When the temperature rises above 100F
- C. When the temperature rises above 102F
- D. When the temperature rises above 99F
Correct Answer: C
Rationale: A rise in temperature is concerning after a medical or surgical procedure as it can indicate infection or other complications. A temperature above 102F is typically considered a significant fever, especially in the postoperative period. It is essential to notify the physician promptly to assess the patient's condition and provide appropriate interventions to address the underlying cause of the fever.
During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his parents left him, and he refused the staff's attention. Now the nurse observes that Eric appears to be "settled in" and unconcerned about seeing his parents. The nurse should interpret this as which statement?
- A. He has successfully adjusted to the hospital environment.
- B. He has transferred his trust to the nursing staff.
- C. He may be experiencing detachment, which is the third stage of separation anxiety.
- D. Because he is "at home" in the hospital now, seeing his mother frequently will only start the cycle again.
Correct Answer: A
Rationale: Eric's change in behavior from crying inconsolably and refusing staff attention to now appearing settled and unconcerned about his parents leaving indicates that he has successfully adjusted to the hospital environment. This adaptation is a positive sign that Eric has become more comfortable with his surroundings and has developed a sense of security within the hospital setting. As a result, the nurse can interpret this change as Eric successfully acclimating to his new environment.
A healthy 4-year-old child has a left flank mass. Computerized tomography (CT) scan of the abdomen shows a localized renal mass. Radical nephrectomy is performed; the histology shows clear cell sarcoma of the kidney. The MOST appropriate next step in the management is
- A. CT scan of the chest
- B. CT scan of the brain
- C. bone scan
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: C
Rationale: Clear cell sarcoma of the kidney has a propensity to metastasize to bones, making a bone scan essential.
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: D
Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.