The nurse is performing a self-breast exam when she discovers a mass. Which characteristic of the mass would be most indicative of a malignancy?
-
Solution
Answer D is correct. A malignant mass is usually firm and hard, usually located in one breast, and not movable with an irregular shape. Answers A, B, and C are not characteristics of a malignancy.
The nurse has just received report from the RN. Which of the following clients should the nurse visit first?
-
Solution
Answer B is correct. The nurse should prioritize these clients and decide to see the client with the shortness of breath because this client is the least stable. Answer A has an abnormal PCO2 (normal 35–45), but this would be expected in a client with COPD. Answer C can be corrected by pain medication and does not require the priority visit. Answer D is incorrect because a temperature elevation of this level would not be a reason for great concern with a client after gallbladder surgery.
A client with ulcerative colitis has impaired nutrition due to diarrhea. Which diet selection by the client would indicate a need for further teaching about foods that can worsen the diarrhea?
-
Solution
Answer A is correct. Clients with ulcerative colitis experiencing diarrhea should avoid bowel irritants such as raw vegetables, nuts, and fatty and fried foods. Answers B, C, and D would not serve as irritants to the bowels.
The nurse recognizes that it would be contraindicated to induce vomiting if someone had ingested which of the following?
-
Solution
Answer D is correct. Vomiting would be contraindicated with an acid, alkaline, or petroleum product. Answers A, B, and C do not contain any of the solutions mentioned in the previous statement.
The nurse is caring for a client recovering from a bone fracture. Which diet selection would be best for this client?
-
Solution
Answer D is correct. This diet selection is the most balanced and best promotes healing. Answers A, B, and C are not as inclusive of food groups that promote healing as answer D.
Acetaminophen (Tylenol) 240mg is ordered for an infant who weighs 12 pounds. The usual dose for an infant is 10–15mg per kilogram of body weight. A nurse should take which action?
-
Solution
Answer D is correct. The dose of medication is too high, so the nurse should contact the physician. The infant weighs 5.45kg; the dose should be between 54.5 and 81.75. Answer A would be an incorrect dose. Answer B would require a new prescription. The action in answer C is not necessary and inappropriate to the situation.
The nurse is caring for a client with a hip fracture who is being discharged with a prescription for alendronate (Fosamax). Which statement would indicate a need for further teaching?
-
Solution
Answer A is correct. Alendronate (Fosamax) should be taken in the morning before food or other medications, with water as the only liquid. Answers B, C, and D are correct administrations. In answer B, remaining upright is important to prevent esophageal problems with Fosamax administration.
The physician has ordered a minimal bacteria diet for a client with cancer. Which seasoning is not permitted for this client?
-
Solution
Answer C is correct. Ground pepper is an unprocessed food and will not be allowed because of the possible bacteria. The nurse would also ensure that this client receives no uncooked fruits and vegetables. Answers A, B, and D have all been through processing.
The nurse is responding to questions from a client with polycythemia vera. Which would be included in the nurses explanations? The client should:
-
Solution
Answer D is correct. Clients with a diagnosis of polycythemia have an increased risk for thrombosis and must be aware of the symptoms. Answers A, B, and C do not relate to this disorder.
A client has been given the drug Neulasta (pegfilgastrin). Which laboratory value indicates that the drug is producing the desired effect?
-
Solution
Answer B is correct. Neulasta is given to increase the white blood cell count in patients with leucopenia. This white blood cell count is within the normal range, showing an improvement. Answers A, C, and D are not specific to the drug’s desired effect.