Nokea
A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is
the first to occur?
- A. Tachycardia
- B. Raynaud's phenomenon
- C. Intense wrinkle
- D. Joint pain
Correct Answer: B
Rationale:
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A nurse is caring for a client who has methicillin-resistant Staphylococcus
aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room
to check the client's pulse. What personal protective equipment (PPE) should
the nurse don?
- A. PAPR mask
- B. Sterile gloves
- C. Gown
- D. Surgical mask
Correct Answer: C
Rationale:
The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
Which of the following lab tests should NOT be used for diagnosing connective tissue
diseases?
- A. Rheumatoid factor (RF)
- B. Erythrocyte sedimentation rate (ESR)
- C. Anti-nuclear antibody (ANA)
- D. Thyroid stimulating hormone (TSH)
Correct Answer: D
Rationale:
A goal for a client with impaired mobility is to prevent skin breakdown. What
nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer the client a bedpan for toileting
- C. Offer a protein-rich diet
- D. Turn the client every 2 hours
Correct Answer: D
Rationale:
What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct Answer: A
Rationale: