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A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply.
- A. Avoid lotions containing calamine.
- B. Take baking soda baths.
- C. Keep nails short and clean.
- D. Rub with knuckles instead of nails.
- E. Massage skin with alcohol.
- F. Increase sodium intake in diet.
Correct Answer: B,C,D
Rationale: Baking soda baths (B), short nails (C), and rubbing with knuckles (D) reduce itching and prevent skin breakdown. Calamine (A) is helpful, not avoided. Alcohol (E) dries skin, worsening irritation. Sodium (F) is unrelated.
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A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
- A. Activity intolerance related to complaints of pain in lower right extremity
- B. Ineffective health maintenance related to lack of knowledge about DVT
- C. Pain related to edema
- D. Risk for impaired skin integrity
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
- A. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath.
- B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain.
- C. A 35-year-old client with suspected tuberculosis who is complaining of a cough.
- D. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (A). The postoperative client with pain (B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (D) is stable.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- A. The client can walk throughout the entire hospital with a walker.
- B. The client can walk the length of a hospital hallway with minimal pain.
- C. The client has increased independence in transfers from bed to chair.
- D. The client can raise the affected leg 6 inches with assistance.
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.
Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?
- A. Skin turgor.
- B. Temperature.
- C. Thirst.
- D. Daily weight.
Correct Answer: D
Rationale: Daily weight reflects fluid balance, which is influenced by glucocorticoid and mineralocorticoid replacement in Addison's disease.