Nokea
While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?
- A. Consuming a high-fat diet
- B. Using tanning beds
- C. Smoking cigarettes
- D. Drinking alcohol
Correct Answer: B
Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.
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At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
- A. Encourage the woman to explore her fears about breast cancer.
- B. Ask the woman if she also performs monthly breast self-exams.
- C. Commend the woman for adhering to the recommended cancer detection guidelines.
- D. Advise the woman that mammograms are only needed every two years at her age.
Correct Answer: B
Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.
A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?
- A. Do not allow the child to return to school for at least one month
- B. Notify the healthcare provider if there is any drainage at the catheterization site
- C. Monitor the child's temperature and report any elevation
- D. Observe for any changes in the child's color or energy level
Correct Answer: B
Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.
The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?
- A. Auscultate the client's breath sounds
- B. Turn the client to the side
- C. Stop the feeding infusion
- D. Notify the healthcare provider
Correct Answer: C
Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.
A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?
- A. Administer 1 mg of glucagon intramuscularly
- B. Provide 15 grams of carbohydrate
- C. Check the client's blood pressure
- D. Notify the healthcare provider
Correct Answer: B
Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.
Is it necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day?
- A. UAPs should follow the prescribed care without questioning it
- B. Yes, it is important to continue straining all the client's urine
- C. Measuring intake and output is equally important as straining the urine
- D. Ensuring that the client is free from pain should be the top priority
Correct Answer: B
Rationale: Yes, it is important to continue straining all urine to catch any remaining stones. Straining the urine helps in identifying any new stones that may have formed, allowing for appropriate management. While measuring intake and output is important, straining the urine is specifically necessary in this case to monitor the presence of kidney stones. Ensuring the client is free from pain is essential, but in this situation, preventing further complications related to kidney stones is a higher priority.