During the assessment of a client's breasts, the nurse finds both ...

[MGLQZ]

During the assessment of a client's breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What is the nurse's next action?
 
  1. Notify the charge nurse.
  2. Notify the physician.
  3. Document the findings in the nurse's notes as normal.
  4. Document the findings in the nurse's notes as abnormal.

Question 2

The nurse is preparing a client for an abdominal examination. What should be done before the examination?
 
  1. Ask client to urinate.
  2. Ask client to drink 8 ounces of water.
  3. Assess vital signs.
  4. Assess heart rate.

[scottmt]

Answer to Question 1

Correct Answer: 3
Rationale 1: The findings are all normal, so the nurse does not need to notify the charge nurse.
Rationale 2: The findings are all normal, so the nurse does not need to notify the physician.
Rationale 3: The findings are all normal, so the nurse would document the assessment in the nurse's notes as normal.
Rationale 4: The findings are all normal, so the nurse would not document the findings as abnormal.

Answer to Question 2

Correct Answer: 1
Rationale 1: The nurse should ask the client to urinate since an empty bladder makes the assessment more comfortable.
Rationale 2: Drinking fluids will cause the client's bladder to fill and cause discomfort.
Rationale 3: The client's vital signs do not need to be assessed prior to an abdominal examination.
Rationale 4: The client does not need to have an apical heart rate assessed prior to having an abdominal assessment.

[MGLQZ]

TYSM

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Gracias!