a nurse is reinforcing teaching with a client about how to perform a breast self exam (BSE). the nurse
should identify which of the following findings as an indication of breast cancer? - CORRECT ANSWER-a
nontender, hard lump that is palpated in one breast - cancerous tumors are typically hard, fixed, irregular
in shape, and nontender to palpation. the nurse should instruct the client to notify the provider promplty if
she palpates a hard, nontender lump
- moveable lumps that increase in tenderness during the menstrual period as an indication of fibrocystic
breast tissue
- multiple masses of regular shaped in both breasts are characteristic of fibrocystic breast disease
- bilaterally darkened areolas are an expected finding in dark-skinned women and an expected change
during pregnancy in light-skinned women
a nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. which of the
following statements by the client indicates a need for further instructions? - CORRECT ANSWER-"I will
cleanse my mouth after meals with an alcohol-based mouthwash." - this client statement indicates a need
for further reinforcement of teaching. clients with stomatitis need to avoid the use of alcohol-based
mouthwash because it can irritate and burn the mucous membrane
- provide oral care with a soft toothbrush or foam swab to prevent additional trauma or bleeding to oral
tissues
- use a straw when drinking liquids to reduce the amount of exposure of liquids on the oral mucosa,
decreasing irritation
- rinse the mouth often with hydrogen peroxide, warm saline, or baking soda solution to promote comfort
and healing
,a nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. which
of the following personal protective equipment (PPE) should the nurse don prior to providing client care?
(SATA) - CORRECT ANSWER-gown - follow standard precautions when caring for a client who has
AIDS. because the bed linens might be soiled,the nurse should don a gown in addition to other
necessary PPE
gloves - standard precautions for client who has AIDS. because the nurse's hands will come into contact
with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE
- mask is not needed when changing the client's bed linens
- hair cover is not needed when changing the client's bed linens
- goggles is not needed since splashing of bodily fluids is unlikely when changing the client's bed linens
a nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her
face. which of the following data should the nurse collect first? - CORRECT ANSWER-respiratory rate -
use the ABC priority-setting framework. the nurse's priority is to collect data about the client's respiratory
status. a client who has burns to her face is at risk for pulmonary injury and the development of rapid,
shallow respirations can indicate a respiratory emergency
- the nurse should determine the percentage of the client's total body surface are that is burned to ensure
proper care and estimation of prognosis, however, the nurse should collect other data first
- nurse should monitor the client's bowel sounds due to the risk for a paralytic ileus; however, the nurse
should collect other data first
- nurse should check the client's level of pain and provide prescribed analgesics; however, the nurse
should collect other data first
, a nurse is reinforcing teaching with a client about preventing the transmission of hepatitis A. the nurse
should identify that hepatitis A is transmitted by which of the following routes? - CORRECT
ANSWER-fecal-oral contamination - hepatitis A is most commonly transmitted by the fecal-oral route.
transmission occurs by ingesting food or liquid that has been infected with the virus. outbreaks due to
contaminated food are usually due to poor hygiene practices by food handlers or shellfish from
contaminated water
- hepatitis B, rather than hepatitis A, is transmitted by several routes, including the maternal-fetal route
- hepatitis B, C, and D rather than hepatitis A, are transmitted by several routes, including unprotected
sexual intercourse
- that hepatitis B and C, rather than hepatitis A, are transmitted by several routes, including blood to
blood exposure
a nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst.
which of the following additional data should the nurse collect? - CORRECT ANSWER-blood glucose
using a glucometer - the nurse should identify that the client's manifestations are indications of
hyperglycemia and diabetic ketoacidosis. the nurse should therefore check the client's blood glucose
level. the nurse should also check the client's respiratory status, vital signs, level of consciousness, and
hydration status, including his electrolyte levels
- identify the probable cause of the client's manifestation and perform a focused data collection of the
affected system, therefore, it is not necessary for the nurse to check the client's pupillary reaction to light
- it is not necessary for the nurse to check the client's deep tendon reflexes
- it is not necessary to check the client's liver function
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