Question

A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?

Answer 1

Correct Answers:

Refrain from using deodorant on the morning of the test.

Rationale :

♦️Deodorants, powders, or lotions can contain metallic particles that may appear as white spots or artifacts on a mammogram image, interfering with accurate results.

♦️Avoiding these products ensures that the breast tissue and surrounding area remain clear for precise imaging and interpretation.

♦️Mammography uses low-dose X-rays to detect breast abnormalities, and clear skin is essential for the radiologist to differentiate normal from abnormal findings.

♦️The nurse should reinforce that normal hygiene like bathing or showering is allowed, but the underarm area should be left product-free.

♦️This teaching promotes test accuracy and patient safety by preventing diagnostic errors.

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Answer 2

Correct Answers:

Onset of urticarial.

Rationale :

✅Urticaria (hives) during a transfusion is a classic sign of a mild allergic reaction to plasma proteins in the donor blood.

✅The immune system recognizes foreign proteins as antigens, leading to histamine release that causes skin manifestations such as itching, rash, and wheals.

✅The nurse should stop the transfusion immediately and notify the provider, keeping the IV line open with normal saline.

✅Monitoring for progression to more severe symptoms like wheezing or anaphylaxis is essential.

✅Early recognition and management help prevent life-threatening transfusion complications.

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Answer 3

Correct Answers:

Ask the client whether they have advance directives.

Rationale :

🟢The nurse’s role is to assess and verify if a client has advance directives upon admission.

🟢This step ensures that the client’s wishes regarding treatment and end-of-life care are known and documented accurately.

🟢It demonstrates respect for autonomy and informed decision-making in healthcare.

🟢If the client does not have an advance directive, the nurse should provide education about their right to complete one.

🟢This action is part of the admission assessment process and aligns with ethical and legal standards in nursing practice.

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Answer 4

Correct Answers:

"You should verify the identity of anyone who wants to remove your baby from the room."

Rationale :

🟠Hospital newborn security relies on verification of staff identity before allowing anyone to take the baby from the mother’s presence.

🟠Nurses and authorized personnel wear photo ID badges with matching information, and parents must confirm this before release.

🟠This procedure prevents infant abduction and ensures adherence to hospital security policies.

🟠The nurse should also remind the parent that the baby should never be left unattended.

🟠Reinforcing this education helps establish trust and awareness between parents and hospital staff.

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Answer 5

Correct Answers:

Instruct the family to bring familiar food from home for the child

Rationale :

☑️Allowing culturally familiar foods respects the family’s cultural and dietary practices while supporting the toddler’s nutritional needs.

☑️This approach helps maintain food acceptance and comfort during hospitalization, reducing stress and appetite loss.

☑️Nurses should promote family-centered care by acknowledging traditional eating habits within safe and appropriate guidelines.

☑️It enhances trust and cooperation between the healthcare team and family.

☑️Culturally sensitive care improves overall satisfaction and adherence to the dietary plan.

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Answer 6

Correct Answers:

"The machine is programmed to prevent you from administering more than a safe dose."

Rationale :

🟣A PCA (Patient-Controlled Analgesia) device is electronically programmed to deliver medication safely within preset limits.

🟣The lockout interval prevents overdose by restricting how frequently the client can self-administer doses.

🟣This technology enhances pain management autonomy while maintaining nurse and provider oversight.

🟣It promotes consistent analgesia without risking respiratory depression from excess dosing.

🟣The nurse reinforces safety, explaining that the system is designed for comfort and protection.

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Answer 7

Correct Answers:

"This test identifies indicators for birth defects."

Rationale :

✔️The quadruple screening test evaluates four maternal serum markers to identify risks for chromosomal abnormalities like Down syndrome and neural tube defects.

✔️It is a screening, not diagnostic, test typically performed at 15–20 weeks gestation.

✔️Abnormal results indicate the need for further diagnostic evaluation, such as amniocentesis or ultrasound.

✔️Early identification allows informed decision-making and early intervention options for the family.

✔️The nurse should reinforce that the test helps estimate the likelihood of fetal abnormalities.

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Answer 8

Correct Answers:

"Are you thinking of harming yourself?"

Rationale :

♦️The nurse’s priority is to assess suicide risk directly using clear and nonjudgmental language.

♦️Asking about suicidal intent determines the immediacy of danger and guides the level of intervention required.

♦️It demonstrates therapeutic communication and empathy by addressing the crisis directly.

♦️This question also allows for prompt safety planning and emergency action if the client confirms intent.

♦️The goal is to ensure client safety and stabilization before further counseling or referral.

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Answer 9

Correct Answers:

pH strips.

Rationale :

✏️When inserting a nasogastric (NG) tube, verifying placement is critical for client safety before use.

✏️Measuring gastric aspirate pH confirms that the tube is in the stomach (usually pH < 5).

✏️Using pH strips is a noninvasive and accurate method for confirming placement at the bedside.

✏️This step prevents aspiration and medication errors associated with tube misplacement.

✏️It is an essential part of safe enteral management and nursing responsibility.

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Answer 10

Correct Answers:

I need to see my child graduate from college before I go

Rationale :

🟢The bargaining stage of grief involves attempting to negotiate or postpone death by making deals or promises.

🟢Clients often express conditional statements in hopes of extending life for significant events.

🟢It reflects the individual’s struggle to regain control and find meaning amid impending loss.

🟢The nurse should recognize this stage as normal and offer emotional support and validation.

🟢Understanding this stage helps the nurse provide compassionate, stage-appropriate care.

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QLexNursing

1 :
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?

2 :
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?

3 :
A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

4 :
A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

5 :
A nurse is assisting with developing a dietary plan for a 2-year-old toddler whose family is from another country. Which of the following recommendations should the nurse make?

6 :
A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of the following statements should the nurse include?

7 :
A nurse is reinforcing teaching about the purpose of quadruple screening for a client who is at 16 weeks of gestation. Which of the following statements should the nurse make?

8 :
A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over. Which of the following is the priority response by the nurse?

9 :
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

10 :
A hospice nurse is caring for a client who has a terminal illness. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of grief?

QLexNursing

1 : A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?

2 : A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?

3 : A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

4 : A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

5 : A nurse is assisting with developing a dietary plan for a 2-year-old toddler whose family is from another country. Which of the following recommendations should the nurse make?

6 : A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of the following statements should the nurse include?

7 : A nurse is reinforcing teaching about the purpose of quadruple screening for a client who is at 16 weeks of gestation. Which of the following statements should the nurse make?

8 : A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over. Which of the following is the priority response by the nurse?

9 : A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

10 : A hospice nurse is caring for a client who has a terminal illness. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of grief?

1 :
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?

2 :
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?

3 :
A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

4 :
A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

5 :
A nurse is assisting with developing a dietary plan for a 2-year-old toddler whose family is from another country. Which of the following recommendations should the nurse make?

6 :
A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of the following statements should the nurse include?

7 :
A nurse is reinforcing teaching about the purpose of quadruple screening for a client who is at 16 weeks of gestation. Which of the following statements should the nurse make?

8 :
A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over. Which of the following is the priority response by the nurse?

9 :
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

10 :
A hospice nurse is caring for a client who has a terminal illness. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of grief?