Nursing Elites

1. A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?

• A. At the onset of menstruation
• B. Every month during ovulation
• C. Weekly, at the same time of day
• D. One week after menstruation begins

Correct answer: D

Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.

2. When planning for the physical assessment of the woman, the nurse ensures that which occurs?

• A. The woman is examined by a female health care provider.
• B. The woman's husband remains in the examining room at all times.
• C. The woman is examined without any other people in the examining room.
• D. Written permission is obtained from the woman to obtain subjective health data.

Correct answer: A

Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.

3. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

• A. The client has a history of Type II diabetes.
• B. The client is on a continuous tube-feeding regimen.
• C. The client is on fluid restriction.
• D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

4. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:

• A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
• B. "Some studies show that ginseng enhances in vitro sperm motility."?
• C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
• D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?

Correct answer: B

Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.

5. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously
• B. give the medications sequentially, and flush well between them
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
• D. start one medication now and begin the other medication in 2-4 hours

Correct answer: B

Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.

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