Nokea
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
- A. Resonance
- B. Flatness
- C. Tympany
- D. Dullness
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.
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A client with a history of breast cancer is prescribed letrozole (Femara). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Letrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
- A. Threatening others and throwing furniture is not allowed.'
- B. You have been restrained until you can manage your behavior.'
- C. Since you have been here before, you know what the rules are.'
- D. We are only doing this for your own good, so calm down.'
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. Which recommendation should the nurse include on the poster?
- A. Use a commercial douche on a daily basis.
- B. Perform monthly breast self-examination (BSE).
- C. Seek treatment promptly if cervical infection is suspected.
- D. Use oral contraceptives as a preferred method of birth control.
Correct Answer: C
Rationale: Early treatment of cervical infection can help prevent chronic cervicitis, which can lead to dysplasia of the cervix. Cervical dysplasia is an early cell change that is considered to be premalignant. Douches and oral contraceptives do not decrease the risk for this type of cancer. BSE is useful for early detection of breast cancer, but is unrelated to cervical cancer.