When teaching a female client to perform breast self-examination, the nurse instructs the client to:
a. Press the pads of the fingers firmly to compress breast tissue against the rib cage.
b. Lie in front of a mirror and observe for dimpling of the skin.
c. Lift the fingers from the chest wall during palpation to better define the breast tissue.
d. Apply gentle pressure to each breast while moving the fingers according to a designated pattern across the breast.
ANS: D
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A nurse is collecting a urine specimen prior to measuring the albumin level in a client's urine. A colleague questions the rationale for the test, stating, "I thought albumin was related to liver function, not kidney function."
How can the nurse best respond to this statement? A) "Urine should normally be free of any proteins, and albumin is one of the more common proteins to be excreted in chronic renal failure." B) "Urine albumin levels are useful for diagnosing diabetic kidney disease." C) "A urine dipstick test will tell us exactly how much albumin is being spilled by the client's kidneys." D) "A urine test for albumin allows us to estimate the client's GFR quite accurately."
The nurse is implementing evidence-based practice when providing patient care. Which action indicates that the nurse implemented this process appropriately?
1. The nurse ended the process by formulating a searchable question. 2. The nurse formulated a searchable question before searching the literature. 3. The nurse applied the result to clinical practice before searching the literature. 4. The nurse evaluated the outcomes of applied evidence before appraising the literature.
A client phones into the physician's office and reports an insect has flown into his ear and asks the nurse what he should do. The nurse instructs him to:
A) irrigate the ear with water to flush out the insect. B) instill mineral oil into the ear canal and try to gently remove insect with tweezers. C) attempt to remove the insect with a cotton-tipped applicator that has been dipped in hydrogen peroxide. D) apply Vaseline to smother and kill the insect.
A child is administered oxybutynin (Ditropan) following surgical repair of a hypospadias. The purpose of this drug is to
A) prevent nausea and vomiting. B) stimulate kidney function. C) acidify urine. D) relieve bladder spasms.