Nokea
A patient asks why it takes so long for fingernails to grow. How should the nurse respond to this patient?
- A. Nail growth speeds up as a person ages.
- B. Nails have a slow but continuous growth process.
- C. Slow nail growth is associated with vitamin deficiencies.
- D. This could mean you have an undiagnosed disease process.
Correct Answer: B
Rationale: Nails grow slowly but continuously throughout life, which explains why it takes time for them to grow.
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The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg / dL, measured this morning. Which nursing action is the priority?
- A. Check the urine specific gravity
- B. Call the health care provider (HCP)
- C. Put the IV line on a pump so that the infusion rate is sure to stay stable
- D. Check to see if the client had a blood sample for a serum albumin level drawn
Correct Answer: B
Rationale: Decreasing urine output and elevated BUN/creatinine suggest renal compromise, requiring HCP notification.
The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer
- B. Refer the client to a prosthesis specialist for prosthesis
- C. Instruct the client how to apply sunscreen to the area
- D. Demonstrate care of the surgical site
Correct Answer: D
Rationale: Post-surgical site care prevents infection and promotes healing, a key discharge instruction.
The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse provides ongoing care and monitoring post-discharge, crucial for TKR recovery.
A patient has lost all hair over the head, face, and neck from a house fire. What should the nurse do to help the patient since the protective function of the hair has been lost?
- A. Increase fluids
- B. Protect the eyes
- C. Provide pain medication
- D. Apply emollient lotion
Correct Answer: B
Rationale: Hair protects eyes from dust and sweat; its loss necessitates eye protection.
An adolescent is in the clinic with a few skin lesions on his thighs. The lesions have an open center with a thin crust. Which question by the nurse will aid the diagnosis of this patients skin problem?
- A. Are you active in any athletics or sports?
- B. Do you have siblings with respiratory infections?
- C. Do you seem to scratch a lot at night?
- D. Have you been in any wooded areas lately?
Correct Answer: A
Rationale: This lesion sounds like MRSA(methicillin-resistant Staphylococcus aureus). MRSA is common in athletes.