Nokea
A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
- A. Papule
- B. Vesicle
- C. Macule
- D. Nodule
Correct Answer: C
Rationale: A macule is a nonpalpable lesion smaller than 1 cm in diameter, such as a freckle.
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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct Answer: A
Rationale: Placing the client on their side with their head forward helps maintain an open airway and prevents aspiration.
A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable?
- A. Family history
- B. Smoking
- C. Age
- D. Gender
Correct Answer: B
Rationale: Smoking is a modifiable risk factor for colorectal cancer.
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skills should the nurse expect?
- A. Walks without assistance using a wide stance
- B. Climbs stairs with assistance
- C. Runs smoothly
- D. Kicks a ball forward
Correct Answer: A
Rationale: At 15 months, toddlers typically walk independently but may do so with a wide stance for balance.
A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Perform palpation before auscultation
- B. Perform percussion before auscultation
- C. Perform palpation after auscultation
- D. Perform inspection after auscultation
Correct Answer: C
Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and then palpation.
A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct Answer: C
Rationale: Crushed tablet medications should be dissolved in 15-30 mL of sterile water to ensure proper delivery through the NG tube.