A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?

Correct Answer: C

Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.

Correct Answer: A

Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.

Correct Answer: B

Rationale: The correct answer is B: maintain blood pressure control. After PTCA, the priority goal is to ensure stable hemodynamics. Maintaining blood pressure control is crucial to prevent complications such as bleeding or thrombosis. Choices A, C, and D are incorrect because preventing fluid volume deficit, decreasing myocardial contractility, and minimizing dyspnea are not immediate priorities post-PTCA. Oxygenation and hemodynamic stability take precedence over these concerns.

Correct Answer: A

Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction. Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.

Correct Answer: A

Rationale: The correct answer is A: Fruits such as bananas. Bananas are high in potassium, which is essential for various bodily functions like muscle contractions and maintaining fluid balance. Fruits are a natural source of potassium and are easily incorporated into the diet. Milk and yogurt (B) are good sources of calcium, not potassium. Green leafy vegetables (C) are nutritious but may not provide as much potassium as fruits. Nuts and legumes (D) are good sources of protein and healthy fats but are not as rich in potassium as fruits like bananas.

Correct Answer: C

Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process checks for errors, inconsistencies, and completeness in the data. By comparing data with other sources, nurses can verify the reliability and correctness of the information. Choice A is incorrect because data validation typically occurs after data collection and before data interpretation. Choice B is incorrect because validation is about ensuring data accuracy, not about professional standards. Choice D is incorrect because data interpretation focuses on analyzing and making sense of the data, not on professional standards or validation processes.

Correct Answer: B

Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed. Step 2: N0 indicates no abnormal regional lymph nodes are involved. Step 3: M0 signifies no evidence of distant metastasis. Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report. Summary: A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor. C: Incorrect - TIS already assesses tumor presence, ruling out this option. D: Incorrect - TIS is not about ascending degrees of distant metastasis.

Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances. Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: B

Rationale: The correct answer is B: Hemorrhage. The nurse manager would intervene because hemorrhage is a life-threatening condition requiring immediate attention. Wandering (A), urinary retention (C), and impaired swallowing (D) are important assessments but do not pose the same level of immediate risk as hemorrhage. The nurse manager would prioritize addressing the hemorrhage to ensure the patient's safety and well-being.