Nokea
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
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A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
- A. Melanoma
- B. Squamous cell carcinoma
- C. Basal cell carcinoma
- D. Kaposi's sarcoma
Correct Answer: C
Rationale: The correct answer is C: Basal cell carcinoma. Basal cell carcinoma typically presents as a raised, flesh-colored lesion with pearly white borders. This type of skin cancer is the most common and is usually slow-growing with low metastatic potential. It is often found on sun-exposed areas such as the face, neck, and chest. Melanoma (A) is characterized by asymmetry, irregular borders, varied color, and a diameter larger than 6mm. Squamous cell carcinoma (B) is usually a firm, red nodule or a flat lesion with a scaly crust. Kaposi's sarcoma (D) typically presents as purple or blue-black patches or nodules on the skin.
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Serous
- B. Sanguineous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection. Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
- A. Dysmenorrhea that is unresponsive to NSAIDs
- B. Heavy menstrual bleeding
- C. Positive family history of fibroids
- D. Pelvic pain after intercourse
Correct Answer: A
Rationale: The correct answer is A: Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis is characterized by severe menstrual pain that is not relieved by NSAIDs. This is due to the abnormal growth of endometrial tissue outside the uterus. Heavy menstrual bleeding (B) is a common symptom but not specific to endometriosis. Positive family history of fibroids (C) is unrelated to endometriosis. Pelvic pain after intercourse (D) can be a symptom of endometriosis but is not as specific as unresponsive dysmenorrhea.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Oral candidiasis
- B. Hypertension
- C. Increased appetite
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Oral candidiasis. Fluticasone is a corticosteroid inhaler commonly used to manage asthma. Corticosteroids can suppress the immune system locally, leading to oral candidiasis. The nurse should monitor for white patches in the mouth. Hypertension (B), increased appetite (C), and weight loss (D) are not commonly associated with fluticasone use.