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 C

Explanation

A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.

A. Decrease the IV fluid infusion rate and limit oral fluid intake. B. Collect a urine specimen for culture and sensitivity. C. Continue routine care because the results are within the expected reference range. D. Evaluate urine output for amount and urine for specific gravity.

Correct Answer is D

Explanation

a. Decrease the IV fluid infusion rate and limit oral fluid intake: The client's BUN and creatinine levels are not significantly elevated, and limiting fluid intake may exacerbate dehydration.

Decreasing the IV fluid rate may not be indicated without further assessment.

b. Collect a urine specimen for culture and sensitivity: While obtaining a urine specimen is

important, the priority in this case is to evaluate the urine output for amount and specific gravity to assess renal function and fluid balance.

c. Continue routine care because the results are within the expected reference range: The elevated BUN, along with nausea and vomiting, suggests the need for further assessment rather than

continuing routine care without adjustments.

d. Evaluate urine output for amount and urine for specific gravity: This is the correct action to assess renal function and fluid balance. Monitoring urine output and specific gravity will help determine if the client's kidneys are effectively concentrating urine and adequately excreting waste products.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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