Which is the first step when teaching a patient to perform a breast self-examination?
1) Using the pads of the fingers to palpate the breast symmetrically
2) Compressing the nipple looking for discharge
3) Inspecting the breasts in the mirror
4) Reporting any redness or inflammation
ANS: 3
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When assessing a patient's pulse, the nurse should also notice which of these characteristics?
a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle
A newly admitted patient required seclusion immediately on entering the inpatient unit. His assessment was incomplete, and no medical orders had been written. Immediately after secluding the patient, the priority action of the nurse should be to:
a. provide a chance for the patient to use the bathroom. b. notify the physician and obtain an order for seclusion. c. complete necessary forms and notify the unit manager. d. debrief the staff and any witnesses to the incident.
Which finding would the nurse suspect as abnormal in the infant during initial assessment?
a. Eyes crossed at times b. Persistent high-pitched cry c. Arms and legs flexed d. Slight bluish tinge of the extremities
Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated. b. Auscultate heart and breath sounds during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.