Nokea
The nurse is teaching a young woman how to perform breast self-examination. Which comment, if made by the client, indicates that the teaching has been effective?
- A. I should examine my breasts every year.'
- B. I need to see the doctor every six months for a breast exam.'
- C. I don't need to worry about breast cancer for a few years.'
- D. I should examine all parts of my breasts while both lying down and standing up.'
Correct Answer: D
Rationale: Effective breast self-examination involves checking all breast areas in both lying and standing positions monthly. Yearly exams, frequent doctor visits, or delaying concern are incorrect.
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A 28-year-old primigravida with pregestational diabetes visits the clinic 6 weeks gestation. Which of the following statements indicates that she understands the nurse's teaching regarding her insulin needs during pregnancy?
- A. As the baby grows, I will need more insulin because the baby will not be able to make insulin.
- B. Changes in hormone levels will make my body more resistant to insulin, so I will need more insulin as the pregnancy progresses.
- C. As the baby grows, I will need less insulin because the baby uses up any extra glucose.
- D. If I maintain an adequate balance of diet and exercise, my insulin requirements will be the same.
Correct Answer: B
Rationale: Pregnancy hormones increase insulin resistance, requiring more insulin as pregnancy progresses in diabetic patients. Other statements are incorrect regarding insulin dynamics.
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, a serious side effect of carvedilol, risking reduced perfusion in heart failure. Options B, C, and D are normal: heart rate 70 bpm, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
A client who has been treated for syphilis.
In preparing discharge plans for a client who has been treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
- A. Practice restraint of sexual activity.
- B. The practice of safe sex.
- C. Information about Planned Parenthood.
- D. Signs of a secondary infection.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not effective in the prevention of transmission of sexually transmitted diseases (2) correct-practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted diseases (3) not as effective in the prevention of transmission of sexually transmitted diseases (4) not as effective in the prevention of transmission of sexually transmitted diseases
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
- A. Heart rate of 90 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.