A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Three to seven days after menses stops.

On the same day every month.

Prior to the beginning of menses.

On the second day of menstruation.

Answer and Explanation

The Correct Answer is A

a. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

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Correct Answer is D

Explanation

a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and

expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.

b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in

asthma exacerbation.

c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma

exacerbation.

d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during

expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.

A. Begin oxygen therapy. B. Start an IV infusion of lactated Ringer’s. C. Initiate cardiac monitoring. D. Administer IV morphine.

Correct Answer is A

Explanation

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is A

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