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A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This viral infection is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution of the vesicles along a dermatome is a key feature of herpes zoster. The other choices are incorrect because: A: Allergic reactions typically present with hives or itching, not vesicles with crusting. B: Ringworm presents as circular, red, scaly patches, not linear clusters of vesicles. C: Systemic lupus erythematosus is an autoimmune disease that manifests with a butterfly rash on the face, joint pain, and other systemic symptoms, not vesicles. Therefore, the nurse should suspect herpes zoster based on the presentation described.
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A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24hr postop to use an incentive spirometer
- B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
- C. Providing nasopharyngeal suctioning for a client who has pneumonia
- D. Replacing the cartridge and tubing on a PCA pump
Correct Answer: D
Rationale: The LPN should question assignment D (replacing the cartridge and tubing on a PCA pump) because this task involves medication administration and intravenous therapy, which are typically outside the LPN's scope of practice. LPNs are not trained to handle complex medication delivery systems like PCA pumps, as this requires specialized knowledge and skills that are within the RN's scope of practice. It is crucial for patient safety that tasks are assigned to healthcare providers based on their education, training, and scope of practice to prevent errors and ensure quality care. Assignments A, B, and C are within the LPN's scope of practice and can be safely performed without questioning.
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead w/the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.
Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take?
- A. Offer to assist the client needing the bedpan.
- B. Administer the injection prepared by the other nurse.
- C. Prepare another syringe & administer the injection.
- D. Tell the client needing the bedpan she will have to wait for her nurse.
Correct Answer: A
Rationale: The correct answer is A. The second nurse should offer to assist the client needing the bedpan. This is important for patient safety and continuity of care. By offering assistance, the second nurse ensures that the immediate needs of the client are met promptly. Administering the injection prepared by the other nurse (B) may lead to errors and violates the principle of accountability. Preparing another syringe and administering the injection (C) is unnecessary and could delay care for the client needing assistance. Telling the client needing the bedpan to wait (D) is not appropriate as it neglects the client's needs.
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
- A. Place the client in semi-Fowler's position
- B. Have the client rest an arm across the abdomen
- C. Observe one full respiratory cycle before counting the rate
- D. Count the rate for one minute if it is regular
- E. Count & report any sighs the client demonstrates
Correct Answer: A, B, C
Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate. Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.