Nokea
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
- A. Cancerous lumps.
- B. Changes from previous self-examinations.
- C. Areas of thickness or fullness.
- D. Fibrocystic masses.
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
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The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
- A. 8 mm Hg
- B. 25 mm Hg
- C. 11 mm Hg
- D. 28 mm Hg
Correct Answer: C
Rationale: The normal range for intraocular pressure (IOP) is approximately 10-21 mm Hg. Choice C has an IOP of 11 mm Hg, falling within this normal range, making it the correct answer. Choices A, B, and D are outside the normal range, with A being too low and B and D being too high, indicating abnormal IOP levels. Choice A (8 mm Hg) is below the normal range, while choices B (25 mm Hg) and D (28 mm Hg) are above the normal range, therefore, they are incorrect answers.
Nursing assessment for a patient with metabolic alkalosis includes evaluation of laboratory data for all of the following except:
- A. Hypocalcemia
- B. Hypokalemia
- C. Hypoglycemia
- D. Hypoxemia
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Hypoglycemia is not directly related to metabolic alkalosis but can be seen in other conditions like diabetes or fasting. Evaluating for hypocalcemia (A) is important as alkalosis can lead to decreased ionized calcium levels. Hypokalemia (B) is common in metabolic alkalosis due to potassium loss. Hypoxemia (D) is not directly related to metabolic alkalosis but can occur in severe cases due to respiratory compensation. Therefore, hypoglycemia is the least relevant in assessing metabolic alkalosis.
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.
Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.
A febrile patient’s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:
- A. 300ml/24hr
- B. 900ml/24hr
- C. 600ml/24hr
- D. 1200ml/24hr
Correct Answer: C
Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.