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Questions 149

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Question 1 of 5

The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

Correct Answer: A

Rationale: The Tail of Spence is the upper outer quadrant of the breast, where an X should be placed, as most breast cancers occur in this area.

Question 2 of 5

The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

Correct Answer: C

Rationale: A heart rate of 60 bpm in a 6-month-old is too low (normal is 80-160 bpm), indicating possible digitalis toxicity, which should be reported.

Question 3 of 5

The client is taking rifampin 600 mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?

Correct Answer: B

Rationale: Rifampin causes orange-red discoloration of urine, a normal side effect the nurse should explain.

Question 4 of 5

Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?

Correct Answer: C

Rationale: Extra fluids in summer prevent dehydration, which can trigger sickle cell crises, indicating parental understanding of disease management.

Question 5 of 5

A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:

Correct Answer: B

Rationale: Glucotrol XL (glipizide) is an oral hypoglycemic agent that works best when taken with breakfast to manage blood glucose levels throughout the day.

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