Nokea
A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first?
- A. document the findings
- B. elevate the breast
- C. encourage nipple massage
- D. notify the physician
Correct Answer: D
Rationale: Deep red color may indicate vascular compromise or infection, requiring immediate physician evaluation.
You may also like to solve these questions
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?
- A. Stridor
- B. Crackles
- C. Scattered rhonchi
- D. Diminished breath sounds
Correct Answer: B
Rationale: Pulmonary edema from MI causes crackles due to fluid in the alveoli.
During an assessment the nurse notes skin changes on the patient's elbows and knees. Which findings support that these changes are plaque psoriasis?
- A. Red raised areas with inconsistent borders
- B. Thick red plaques covered with silvery scales
- C. Large reddened areas of weeping and maceration
- D. Small raised and reddened areas with fluid-filled pustules
Correct Answer: B
Rationale: Plaque psoriasis typically presents as thick red plaques with silvery scales, especially on extensor surfaces like elbows and knees, distinguishing it from other descriptions.
The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a key long-term goal for managing pruritus and preventing complications like infections.
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
- A. Alteration in comfort.
- B. Risk for depressed respiratory pattern.
- C. Potential for infection.
- D. Fluid and electrolyte imbalance.
Correct Answer: B
Rationale: Narcan reverses opioid-induced respiratory depression, highlighting the risk for respiratory complications.
A client is scheduled to undergo a prostate biopsy. When providing education concerning postoperative care related to the procedure, which of the following should be included?
- A. Avoid strenuous activity for 24 hours.
- B. There may be discomfort for 24-48 hours after the procedure.
- C. The client can immediately return to his preprocedure activity level.
- D. The names of sexual contacts must be collected.
Correct Answer: B
Rationale: The client might experience discomfort for 1-2 days after the procedure. Strenuous activity is avoided for only about 4 hours, not 24, and sexual contacts are irrelevant.