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?

Lumps that are mobile and tender upon palpation prior to a menstrual period.

Multiple round masses that are tender and found in both breasts

Bilaterally darkened areolas

A nontender hard lump that is palpated in one breast

Answer and Explanation

The Correct Answer is D

Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.

Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.

Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.

Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.

Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

A. Raising the bed linens off the client's feet to prevent plantar flexion. B. Keeping the client's heels off the bed to prevent pressure ulcers. C. Positioning the client off the operative site while in bed. D. Preventing dislocation of the hip during position changes or movement.

Correct Answer is D

Explanation

Choice A reason: This is an incorrect purpose, because raising the bed linens off the client's feet to prevent plantar flexion is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Raising the bed linens off the client's feet can be achieved by using a foot cradle or a bed frame.

Choice B reason: This is an incorrect purpose, because keeping the client's heels off the bed to prevent pressure ulcers is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Keeping the client's heels off the bed can be achieved by using a heel protector or a pillow under the lower legs.

Choice C reason: This is an incorrect purpose, because positioning the client off the operative site while in bed is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Positioning the client off the operative site can be achieved by using a trochanter roll or a pillow under the hip.

Choice D reason: This is the correct purpose, because preventing dislocation of the hip during position changes or movement is the main reason for using an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

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?

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

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? (Select all that apply.)

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?

A nurse is reinforcing teaching with a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?

A nurse in an urgent care clinic is collecting data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of a skull fracture?

A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?