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When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?
- A. It is not necessary to wash your hands as long as you use gloves.'
- B. Handwashing is the best method for preventing cross-contamination.'
- C. Waterless commercial products are not effective for killing organisms.'
- D. The hands do not serve as a source of infection.'
Correct Answer: B
Rationale: Handwashing is the most effective method to prevent cross-contamination, as hands are a primary source of infection transmission in healthcare settings.
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A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?
- A. Slow movements.
- B. Flat affect.
- C. Unkempt appearance.
- D. Avoidance of eye contact.
Correct Answer: A
Rationale: Slow movements are a hallmark of psychomotor retardation, often seen in depression or other psychiatric conditions.
A client with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates the medication is effective?
- A. Increased blood pressure.
- B. Decreased edema.
- C. Weight gain.
- D. Elevated potassium levels.
Correct Answer: B
Rationale: Furosemide is a diuretic that reduces fluid overload, so decreased edema indicates effective treatment by promoting fluid excretion.
When the nurse is assessing a client's cultural adaptation, which of the following statements is least sensitive to the client's needs?
- A. What are some of your favorite foods?'
- B. Describe any health problems in your past.'
- C. Please tell me how you would like to be addressed.'
- D. Your eyes look dark; is this normal for you?'
Correct Answer: D
Rationale: Commenting on the client's appearance (dark eyes) is insensitive and irrelevant to cultural adaptation, potentially making the client uncomfortable.