This medical-surgical nursing practice is related to cancer of the breast, colostomy, rhinorrhea, testicular examinations, ventilator, and Addisonian crisis.
A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
|a. eversion of the right nipple and a mobile mass|
|b. nonmobile mass with irregular edges|
|c. mobile mass that is oft and easily delineated|
|d. nonpalpable right axillary lymph nodes|
B is the correct answer. Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retraction—not eversion—may be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass
A client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which a member of the health care team?
|a. Social worker|
|b. registered dietician|
|c. occupational therapist|
|d. enterostomal nurse therapist|
D is the correct answer. An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.
Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?
A is the correct answer. Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.
A male client should be taught about testicular examinations
|a.when sexual activity starts|
|b.after age 60|
|c. after age 40|
|d. before age 20|
D is the correct answer. Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.
Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
|A. fluid intake for the last 24 hours|
|B. baseline arterial blood gas (ABG) levels|
|C. prior outcomes of weaning|
|D. electrocardiogram (ECG) results|
B is the correct answer. Before weaning a client from mechanical ventilation, it’s most important to have baseline ABG levels. During the weaning process, ABGlevels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.
Practice Question Test
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and arterial oxygen saturation (SaO2) 96% or better. The client most likely has
|A. poor peripheral perfusion|
|B. a possible Hematologic problem|
|C. a psychosomatic disorder|
|D. left-sided heart failure|
B is the correct answer. SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesn’t indicate the client’s overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn’t enough data to assume that the client’s problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.
For a client in Addisonian crisis, it would be very risky for a nurse to administer
|A. potassium chloride|
|B. normal saline solution|
A is the correct answer. The Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, a normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.
The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature
D is the correct answer. Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.
The nurse is performing wound care on afoot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
|A. Putting on sterile gloves then opening a container of sterile saline.|
|B. Cleaning the wound with a circular motion, moving from outer circles toward the center.|
|C. Changing the sterile field after sterile water is spilled on it.|
|D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.|
C is the correct answer. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren’t sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area—for example, from the center outward. The outer inch of a sterile field shouldn’t be considered sterile.
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
|A. high volumes of fluid intake|
|B. aerobic exercise programs|
|C. caffeine-containing products|
|D. foods rich in protein|
C is the correct answer. Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high-calorie foods are.