Nokea
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
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A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid rate
- B. Pedal pulses
- C. Nasal cannula flow rate
- D. Capillary refill
Correct Answer: B
Rationale: A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.
The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?
- A. Use of alcohol.
- B. Frequent use of mouthwash.
- C. Lack of vitamin B12.
- D. Lack of regular teeth cleaning by a dentist.
Correct Answer: A
Rationale: Alcohol use is a well-established primary risk factor for oral cancer, often acting synergistically with tobacco use. Frequent mouthwash use, vitamin B12 deficiency, and lack of dental cleanings are not primary risk factors for oral cancer.
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
- A. Maintain sterile technique.
- B. Use a mask, gloves, and a gown when assisting with the procedure.
- C. Place the specimen in a container and send it to the laboratory when someone is available to take it.
- D. Call for a laboratory technician to assist the physician.
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.
A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
- A. Reinforce the aide's use of this intervention over the bony prominences.
- B. Explain that massage is effective because it improves blood flow to the area.
- C. Inform the aide that massage is even more effective when combined with lotion during the massage.
- D. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.