A nurse is conducting a class on BSE.
Which statement indicates the proper BSE technique?
The best time to perform BSE is in the middle of the menstrual cycle.
If she suspects she is pregnant, then the woman should not perform a BSE until after her baby is born.
A woman should perform BSEs bimonthly unless she has fibrocystic breast tissue.
The best time to perform a BSE is 4-7 days after the first day of the menstrual period.
The Correct Answer is D
Choice A rationale
The middle of the menstrual cycle is when hormonal fluctuations are highest, which can cause breast tenderness and lumpiness, potentially making it more difficult to distinguish normal breast tissue from abnormalities during a BSE.
Choice B rationale
Pregnancy causes significant hormonal changes that lead to breast enlargement and increased nodularity, making BSE more challenging and potentially causing unnecessary anxiety. However, it is still important for pregnant women to be aware of their breasts and report any unusual changes to their healthcare provider.
Choice C rationale
BSE should be performed monthly, not bimonthly, to ensure regular self-examination. While women with fibrocystic breast tissue may have more lumps and bumps, regular monthly BSE is still important for them to become familiar with their normal breast tissue and identify any new or changing lumps.
Choice D rationale
The optimal time to perform a BSE is 4-7 days after the start of the menstrual period. At this point in the cycle, hormone levels are typically at their lowest, and the breasts are less likely to be swollen or tender, making it easier to detect any abnormalities. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
Choice A rationale
Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.
Choice B rationale
Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.
Choice C rationale
Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.
Choice D rationale
Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.
Correct Answer is ["0.17"]
Explanation
Step 1: The ordered dose is 17 units.
Step 2: The concentration of the insulin is 100 units/mL.
Step 3: To find the volume to administer, divide the ordered dose by the concentration: 17 units ÷ 100 units/mL = 0.17 mL.
Final answer: The nurse will administer 0.17 mL.
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