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Questions 158

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Question 1 of 5

A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

Correct Answer: B

Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.

Question 2 of 5

The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:

Correct Answer: D

Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.

Question 3 of 5

The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?

Correct Answer: B

Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (
A), hoarseness (
C), and mild fever (
D) are expected post-op.

Question 4 of 5

Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?

Correct Answer: C

Rationale: Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. Early menopause decreases the risk of developing breast cancer.

Question 5 of 5

A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:

Correct Answer: B

Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.

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