Question

A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

Answer 1

Correct Answers:

"Breast cancer can occur in any part of the breast, but ductal breast cancer is most common."

Rationale :

✔️Most breast cancers originate in the ducts that carry milk toward the nipple, making ductal carcinoma the most common type of breast cancer.

✔️Invasive ductal carcinoma begins in a milk duct and can invade surrounding breast tissue and potentially spread to other parts of the body.

✔️Breast cancer can also arise from the lobules, connective tissue, nipple, or other structures within the breast.

✔️Early recognition and appropriate screening can improve the likelihood that breast cancer is identified before it has significantly progressed.

✔️Teaching clients that ductal cancers are the most common helps them understand the basic anatomy and disease process of breast malignancy.

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Answer 2

Correct Answers:

Explain the risk the client faces if she leaves the facility.

Rationale :

✳️ A competent adult has the right to leave the hospital against medical advice, even when the healthcare team believes remaining would be safer.

✳️ The nurse should explain the potential risks associated with leaving, including the implications of an elevated INR and increased bleeding risk while taking warfarin.

✳️ Providing clear information supports informed decision-making and allows the client to understand possible consequences before leaving.

✳️ The nurse should notify the provider, document the discussion objectively, and offer the appropriate AMA documentation without coercing the client.

✳️ Respecting the client's autonomy while providing accurate risk information is the appropriate nursing response.

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Answer 3

Correct Answers:

Excessive thrombosis and bleeding

Rationale :

🧿 DIC causes widespread activation of the coagulation cascade, producing numerous small clots throughout the microcirculation.

🧿 Formation of these clots consumes platelets and clotting factors, creating a consumptive coagulopathy.

🧿 As clotting components become depleted, the client develops abnormal bleeding from wounds, venipuncture sites, mucous membranes, or internal organs.

🧿 Microvascular thrombosis can also impair tissue perfusion and contribute to organ ischemia and failure.

🧿 DIC is therefore characterized paradoxically by both excessive clotting and excessive bleeding.

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Answer 4

Correct Answers:

Sepsis

Rationale :

♦️ Sepsis is one of the most common and important causes of acute respiratory distress syndrome because systemic inflammation can severely damage the pulmonary capillary membrane.

♦️ Inflammatory mediators increase capillary permeability, allowing protein-rich fluid to leak into the alveoli and produce noncardiogenic pulmonary edema.

♦️ Fluid-filled alveoli cause severe impairment of oxygen diffusion, decreased lung compliance, and refractory hypoxemia.

♦️ Clients with sepsis are therefore monitored closely for increasing respiratory distress, tachypnea, and worsening oxygenation.

♦️ Recognizing sepsis as a major precipitating factor helps nurses identify clients at high risk for developing ARDS.

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Answer 5

Correct Answers:

Verify that the suction regulator is on and check the tubing for leaks.

Rationale :

🖍️ In a traditional wet-suction chest drainage system, gentle bubbling in the suction control chamber indicates that suction is functioning.

🖍️ Absence of bubbling can mean the wall suction is not turned on, the suction level is inadequate, or the system has a disconnection or leak.

🖍️ The nurse should first assess the suction source and tubing connections to determine whether negative pressure is being delivered correctly.

🖍️ Restoring proper suction helps maintain lung re-expansion and promotes removal of air and fluid from the pleural space.

🖍️ The nurse should also assess the client's respiratory status and verify that the drainage system remains below chest level and upright.

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Answer 6

Correct Answers:

Limit visitors to healthy adults.

Rationale :

♠️ An ANC below 1,000/mm³ indicates significant neutropenia, placing the client at increased risk for serious infection.

♠️ Visitors should be screened for illness, and individuals with fever, respiratory symptoms, recent infection, or other contagious conditions should not enter.

♠️ Limiting exposure to healthy visitors decreases the client's contact with potential bacterial, viral, and fungal pathogens.

♠️ Meticulous hand hygiene, careful food preparation, and avoidance of invasive rectal procedures are also important infection-prevention measures.

♠️ Restricting visitors to healthy individuals therefore supports protective measures for the client's compromised immune system.

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Answer 7

Correct Answers:

antiplatelet aggregate

Rationale :

🧡 Aspirin irreversibly inhibits platelet aggregation by blocking cyclooxygenase and decreasing thromboxane A₂ production.

🧡 Reduced platelet activity decreases the likelihood of forming an occlusive coronary thrombus.

🧡 Following myocardial infarction, preventing additional platelet aggregation lowers the risk for recurrent MI and other cardiovascular events.

🧡 Aspirin is therefore a cornerstone medication in secondary prevention of atherosclerotic cardiovascular disease when not contraindicated.

🧡 The intended therapeutic effect in this client is antiplatelet activity, not primarily pain, fever, or inflammation control.

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Answer 8

Correct Answers:

1 cup canned black beans

Rationale :

✍️ Black beans are a good source of nonheme iron, making them useful in a diet designed to improve iron intake.

✍️ Iron is needed for synthesis of hemoglobin, which transports oxygen throughout the body.

✍️ Increasing iron-rich foods can help correct fatigue, weakness, and other manifestations associated with iron deficiency anemia.

✍️ Absorption of plant-based iron improves when it is eaten with vitamin C-rich foods, such as citrus fruit, tomatoes, or peppers.

✍️ Black beans are therefore the best option among the choices for increasing dietary iron intake.

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Answer 9

Correct Answers:

The client has hypotension and is confused

Rationale :

🔆 Hypotension is a major sign of inadequate circulating volume or impaired tissue perfusion during shock.

🔆 Confusion or altered mental status occurs when cerebral perfusion and oxygen delivery become insufficient.

🔆 Postoperative clients may develop shock from hemorrhage, fluid loss, cardiac dysfunction, sepsis, or other causes.

🔆 Additional findings may include tachycardia, cool clammy skin, decreased urine output, weak pulses, and metabolic acidosis.

🔆 The combination of hypotension and confusion therefore requires rapid intervention to restore circulation and organ perfusion.

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Answer 10

Correct Answers:

Continue to monitor the client's respiratory status.

Rationale :

📌Slow, gentle, continuous bubbling in the suction control chamber of a wet-suction system is expected and indicates that suction is functioning.

📌The bubbling should remain gentle rather than vigorous because excessive bubbling increases evaporation and does not increase therapeutic suction.

📌The nurse should continue to assess the client's breath sounds, oxygenation, respiratory effort, drainage, and chest-tube system.

📌Bubbling in the suction control chamber should not be confused with continuous bubbling in the water-seal chamber, which may indicate an air leak.

📌Because the system is functioning as intended, continued respiratory monitoring is the appropriate nursing action.

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Custom NUR 211 Final Assessment- Spring 1 2026

No.

1 :
A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

3 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following conditions is the most common cause of ARDS?

6 :
A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

7 :
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

8 :
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

9 :
A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

10 :
A nurse is observing the closed chest drainage system of a client who is 24hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

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Custom NUR 211 Final Assessment- Spring 1 2026

No.

1 : A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

3 : A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 : A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following conditions is the most common cause of ARDS?

6 : A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

7 : A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

8 : A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

9 : A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

10 : A nurse is observing the closed chest drainage system of a client who is 24hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

1 :
A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

3 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following conditions is the most common cause of ARDS?

6 :
A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

7 :
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

8 :
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

9 :
A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

10 :
A nurse is observing the closed chest drainage system of a client who is 24hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?