Nokea
An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
- A. Use the present solution with the new tubing
- B. Connect the new tubing to the hub prior to running any fluid through the tubing
- C. Close the roller clamp on the new tubing after priming it
- D. Have the client roll to the right side to prevent an air embolus
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
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The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
- A. hypotension
- B. thick, coarse skin
- C. deposits of adipose tissue in the trunk and dorsocervical area
- D. weight gain in arms and legs
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.
A client asks the nurse what PSA is. The nurse should reply that is stands for:
- A. Prostate-specific antigen, which is used to screen for prostate cancer
- B. Protein serum antigen, which is used to determine protein levels
- C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
- D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use.
Summary of Incorrect Choices:
B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels.
C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening.
D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
A female client recovers from a serious case of insect bites. What skin related advice must the nurse give to the client and all her family members to prevent the recurrence of the ailment?
- A. Ensure minimum crowd interactions when outdoors
- B. Apply insect repellent to clothing and exposed skin
- C. Wear thick woollen clothing to cover the skin while outdoors
- D. Apply a good sunscreen lotion while going outdoors
Correct Answer: B
Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.