When performing a clinical breast examination, which would the nurse do first?

Inspect the breasts.

Palpate the axillary area.

Compress the nipple for a discharge.

Palpate the breasts.

Answer and Explanation

The Correct Answer is A

A. Inspect the breasts:

Inspecting the breasts visually is usually the first step in a clinical breast examination. The nurse observes the size, shape, symmetry, and skin characteristics of the breasts, including any visible abnormalities such as dimpling, puckering, or changes in skin texture or color.

B. Palpate the axillary area:

Palpating the axillary (underarm) area is typically done after inspecting the breasts. This allows the nurse to assess for any enlarged lymph nodes or palpable masses in the axillary region, which could indicate pathology or breast cancer metastasis.

C. Compress the nipple for a discharge:

If there are concerns about nipple discharge, this step may follow breast palpation. By gently compressing the nipple, the nurse can assess for any abnormal discharge, such as bloody or spontaneous discharge, which may warrant further investigation.

D. Palpate the breasts:

Palpating the breasts is usually performed after visual inspection and axillary palpation. During breast palpation, the nurse systematically examines each breast using circular motions with varying pressure to detect any lumps, masses, or areas of tenderness. This thorough palpation helps identify any abnormalities within the breast tissue.

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Correct Answer is C

Explanation

A. Have the technician come back later on:

This option suggests delaying the blood draw until a later time when the IV line is removed or after the infusion is completed. While this may seem like a reasonable approach to avoid interfering with the IV line, it could lead to unnecessary delays in obtaining essential laboratory test results.

B. Notify the surgeon to obtain the specimen via a cut-down procedure:

This option involves a more invasive procedure, called a cut-down, which is typically reserved for situations where peripheral venous access is challenging or impossible. It involves making an incision to expose a vein for direct cannulation. This approach is not warranted in this scenario, where obtaining blood from the opposite arm is a standard and less invasive practice.

C. Tell the technician to obtain the specimen from the client's left arm:

This option is the most appropriate response. It instructs the technician to draw blood from the client's left arm, which is free from the IV line. Drawing blood from the opposite arm minimizes the risk of complications associated with interfering with the IV infusion.

D. Stop the technician immediately:

While stopping the technician immediately may prevent them from proceeding with the incorrect approach, it lacks specific guidance on how to proceed correctly. It's essential to provide clear instructions to the technician to draw blood from the opposite arm rather than simply halting the procedure without further direction.

A. 1,000 cells/mm3 B. 700 cells/mm3 C. 450 cells/mm3 D. 200 cells/mm3

Correct Answer is D

Explanation

A. 1,000 cells/mm3:

A CD4 cell count of 1,000 cells/mm3 is within the normal range for a healthy individual. In HIV-positive individuals, a CD4 count at this level would generally indicate that the immune system is functioning well and has not been significantly compromised by the virus. Therefore, a CD4 count of 1,000 cells/mm3 would not suggest a diagnosis of AIDS.

B. 700 cells/mm3:

Similarly, a CD4 cell count of 700 cells/mm3 is also within the normal range for immune function. While this count may be lower than the typical CD4 count in a healthy individual, it is still considered relatively high and would not indicate immune compromise to the extent seen in AIDS.

C. 450 cells/mm3:

A CD4 cell count of 450 cells/mm3 is also within a range that suggests the immune system is functioning reasonably well. While it may be lower than normal, it is not at a level indicative of severe immune suppression characteristic of AIDS.

D. 200 cells/mm3:

When the CD4 cell count drops below 200 cells/mm3, it indicates significant immune suppression and an increased risk of opportunistic infections. This threshold is used to diagnose AIDS in HIV-positive individuals. At this level, the immune system is severely compromised, leaving the individual vulnerable to various infections and diseases associated with AIDS.

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When performing a clinical breast examination, which would the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse reviews the CD4 cell count of a client who is HIV-positive. A result less than which count would indicate to the nurse that the client has AIDS?

Correct Answer is D

Explanation

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