During a routine breast examination of a patient, the nurse notes a small amount of nipple discharge. What nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Tell the patient she may have cancer.
2. Send the specimen to the lab.
3. Ask the patient if she has noticed discharge before.
4. Collect a specimen on a slide.
5. Document the finding.
2,3,4,5
Rationale 1: Telling the patient she has cancer is inappropriate; discharge is not always a sign of cancer.
Rationale 2: The nipple drainage would be sent to the lab for analysis.
Rationale 3: The nurse would question if this discharge has occurred before and when it began.
Rationale 4: The drainage should be collected on a specimen slide.
Rationale 5: The nurse would document the finding so that future comparisons can be made if the drainage continues.
You might also like to view...
You are the nurse caring for a patient who is scheduled to have a thoracotomy. You are planning to provide preoperative teaching and know to share what information with the patient?
A) How to milk the chest tubing B) How to splint the incision when coughing C) How to care for the wound D) How to recognize signs of respiratory distress
A patient is diagnosed with acute hemorrhage from esophageal varices. Which of the following should the nurse suspect as the cause for this diagnosis?
1. gastritis from NSAIDs use 2. reflux esophagitis 3. gall stones 4. portal hypertension with shunting of blood
A patient has been taking fluoxetine (Prozac) for 11 months and reports feeling cured of depression
The nurse learns that the patient is sleeping well, participates in usual activities, and feels upbeat and energetic most of the time. The patient's weight has returned to normal. What will the nurse tell this patient? a. Indefinite drug therapy is necessary to maintain remission. b. Discuss gradual withdrawal of the medication with the provider. c. Stop the drug while remaining alert for the return of symptoms. d. Take a drug holiday to see whether symptoms recur.
You are in the middle of your shift in the coronary care unit (CCU) of a large urban medical center. Your new admission, C.B., a 47-year-old woman, was just flown to your institution from a small rural community more than 100 miles away
She had a STEMI (ST segment elevation myocardial infarction) last evening. Her current vital signs (VS) are 100/60, 86, 14. After you make C.B. comfortable, you receive this report from the flight nurse: "C.B. is a full-time homemaker with four children. She has had episodes of 'chest tightness' with exertion for the past year, but this is her first known MI. She has a history of hyperlipidemia and has smoked one pack of cigarettes daily for 30 years. Surgical history consists of total abdominal hysterectomy 10 years ago after the birth of her last child. She has no other known medical problems. Yesterday at 8 pm, she began to have severe substernal chest pain that referred into her neck and down both arms. She rated the pain as 9 or 10 on a 0-to-10 scale. She thought it was severe indigestion and began taking Maalox with no relief. Her husband then took her to the local emergency department, where a 12-lead electrocardiogram (ECG) showed hyperacute ST elevation in the inferior leads II, III, aVF and V5 to V6. Before tissue plasminogen activator could be given, she went into ventricular fibrillation (V-fib). CPR was started and when the code team arrived, she was successfully defibrillated after two shocks. She then was started on nitroglycerin (NTG), heparin, and amiodarone drips. She was given IV metoprolol and aspirin 325 mg to chew and swallow. This morning her systolic pressure dropped into the 80s, and she was placed on a low-dose norepinephrine drip and urgently flown to your institution for coronary angiography and possible percutaneous transluminal coronary angioplasty. Currently, she has amiodarone infusing at 1 mg/min, heparin at 1200 units/hr, and norepinephrine at 0.5 mcg/kg/min. The NTG has been stopped because of low blood pressure. Laboratory work that was done yesterday showed Na 145 mEq/L, K 3.6 mEq/L, HCO3 19 mEq/L, BUN 9 mg/dL, creatinine 0.8 mg/dL, WBC 14,500/mm3, Hct 44.3%, and Hgb 14.5 g/dL." Because the 12-lead ECG can tell you the location of the infarction, evaluate the leads that showed ST elevation. What areas of C.B.'s heart have been damaged? Given the diagnosis of acute myocardial infarction (MI), what other laboratory results are you going to look at? Indicate the expected outcome for C.B. associated with each medication she is receiving. For each of the drugs listed, state the purpose. a. Intravenous (IV) nitroglycerin (NTG) b. IV heparin c. IV amiodarone d. IV metoprolol e. Aspirin, chewed and swallowed f. IV norepinephrine Laboratory Test Results Creatine Phosphokinase (CK) Levels On ED admission 95 units/L 4 hours 1931 units/L 8 hours 4175 units/L CK-MB Isoenzymes On ED admission 5% 4 hours 79% 8 hours 216% LDL 160 mg/dL PT 11.9 sec INR 1.02 aPTT (before heparin) 26.9 sec Mg 2.2 mg/dL K 3.3 mEq/L You review the lab work on her chart. For each laboratory value listed previously, interpret the result, and evaluate the meaning for C.B. List at least two complications C.B. is at risk for at this time and the assessments that are needed to identify these risks. You note that C.B.'s Spo2 on oxygen (O2) at 6 L/min by nasal cannula is 92%. How do you interpret this result? What can be done to promote her oxygenation at this time?