Nokea
A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
- A. Recommend a dermatological consult to the MD.
- B. Note the location of the mole and contact the physician via the telephone.
- C. Note the location of the mole and follow-up with the attending physician via the medical record and phone call.
- D. Remove the mole with a sharp's debridement technique, following charge nurse approval.
Correct Answer: C
Rationale: Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.
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The client is admitted to the unit with the following lab values. Which of the following lab values should be reported immediately?
- A. BUN $18 \mathrm{mg} / \mathrm{dL}$
- B. $\mathrm{PO}_2 72 \%$
- C. Hemoglobin $10 \mathrm{mg} / \mathrm{dL}$
- D. White blood cell count of 5,500
Correct Answer: B
Rationale: A $\mathrm{PO}_2$ of 72% indicates severe hypoxemia, requiring immediate intervention. BUN, hemoglobin, and WBC values are less urgent.
The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV?
- A. Insulin.
- B. Glucose.
- C. Phenobarbital.
- D. Calcium gluconate.
Correct Answer: D
Rationale: Hypocalcemia (7.0 mg/dL) in infants of diabetic mothers risks tetany; calcium gluconate is indicated. Options A, B, and C are inappropriate.
An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.
A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The patient keeps sliding down in bed.
The nurse should
- A. elevate the patient's left thigh on two pillows.
- B. elevate the foot of the bed on blocks.
- C. raise the knee gatch on the bed 30°.
- D. instruct the patient to remain in the middle of the bed.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not prevent patient from sliding down; may change pull of traction (2) correct-will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the patient from sliding down in bed