A nurse is teaching a female young adult client about performing a breast self-examination. Which of the following instructions should the nurse include in the teaching?

"Report a firm ridge below the breasts to the provider."

"Keep your arm relaxed at your side on the side you are examining."

"Use your thumb and forefinger to palpate each breast for lumps."

"Use firm pressure to palpate near the area of the ribs and chest wall."

Answer and Explanation

The Correct Answer is D

A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Avoid using moisturizers on the client's skin. Moisturizers are important for maintaining skin integrity, especially in clients with incontinence, to prevent skin breakdown.
B. Place the client on a timed voiding schedule. This is correct. A timed voiding schedule can help manage incontinence by reducing the frequency of wetness and thereby preventing skin breakdown.
C. Place the client in high-Fowler's position while in bed. High-Fowler’s position is not typically indicated for preventing skin breakdown and can increase pressure on the sacral area.
D. Wash urine off the client's skin with hot water and soap. Washing with hot water and soap can be harsh and irritating to the skin. It is better to use mild soap and lukewarm water.

A. Complete an incident report and notify the nursing supervisor. B. Direct the provider to the admissions department for the information. C. Place a cover sheet on top of the document indicating the recipient. D. Fax the complete medical record to the provider's office.

Correct Answer is C

Explanation

A. Complete an incident report and notify the nursing supervisor. Completing an incident report and notifying the supervisor is not required for routine tasks like faxing a laboratory report.
B. Direct the provider to the admissions department for the information. Directing the provider to another department is not necessary for this task and does not address the specific request to fax the report.
C. Place a cover sheet on top of the document indicating the recipient. This is the correct action. A cover sheet helps protect patient confidentiality by indicating the intended recipient and purpose of the fax, ensuring secure transmission.
D. Fax the complete medical record to the provider's office. Faxing the complete medical record is inappropriate unless specifically requested. Only the relevant laboratory report should be sent to maintain patient confidentiality and comply with privacy regulations.

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A nurse is teaching a female young adult client about performing a breast self-examination. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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