Nokea
At the first dressing change, the PN tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?
- A. You will feel better when you see that the incision is not as bad as you may think.
- B. It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.
- C. Part of recovery is accepting your new body image, and you will need to look at your incision.
- D. Would you like me to call another nurse to be here while I show you the wound?
Correct Answer: B
Rationale: Acknowledging the client's feelings and providing emotional support without pressuring them to look at the incision is important. Choice B is the best response as it respects the client's emotional readiness to confront their body image changes. The client's autonomy and emotional needs are prioritized in this response. Choice A may invalidate the client's feelings by assuming the incision is not as bad as they think, potentially dismissing their emotions. Choice C is insensitive as it imposes a particular view of recovery on the client, disregarding their current emotional state. Choice D may escalate the situation by suggesting the need for another nurse, which could make the client feel uncomfortable and pressured.
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After administering pantoprazole to a client with gastroesophageal reflux disease (GERD), which statement by the client indicates to the nurse that the medication is producing the desired effect?
- A. After eating my meal, I did not experience any heartburn
- B. I have a great appetite and am feeling really hungry
- C. I should increase the amount of vitamin C in my diet
- D. While eating, I had no difficulty swallowing any of the foods
Correct Answer: A
Rationale: The correct answer is A. Pantoprazole reduces stomach acid production, thus preventing the occurrence of heartburn after meals, which is a common symptom of GERD. Choice B is incorrect because an increased appetite and hunger are not indicators of the desired effect of pantoprazole. Choice C is unrelated to the medication's effect on GERD symptoms. Choice D is also incorrect because the absence of difficulty swallowing is not a specific indicator of pantoprazole's effectiveness in treating GERD.
Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the PN to review?
- A. Hemoglobin and Hematocrit
- B. Serum Calcium
- C. Serum Creatinine
- D. WBC
Correct Answer: C
Rationale: Serum creatinine is the most important lab value to review before administering an antibiotic that can cause nephrotoxicity. This is because serum creatinine is a key indicator of kidney function. An elevated serum creatinine level may indicate impaired renal function, and administering nephrotoxic drugs in such situations can further damage the kidneys. Monitoring serum creatinine levels helps healthcare providers assess renal function and make informed decisions regarding drug administration. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity, making them less crucial in this scenario. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels are more related to bone health and nerve function, and WBC count is associated with immune response, none of which directly reflect kidney function or the risk of nephrotoxicity.
A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?
- A. Report the finding to the healthcare provider
- B. Place a clear occlusive dressing over the site
- C. Apply a warm compress to remove the crusted area
- D. Explain that this is a normal skin change with aging
Correct Answer: A
Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.
Which task could the nurse safely delegate to the UAP?
- A. Oral feeding of a two-year-old child after application of a hip spica cast
- B. Assessment of the placement and patency of an NG tube
- C. Participation in staff rounds to record notes regarding client goals
- D. Evaluation of a client's incisional pain following narcotic administration
Correct Answer: A
Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.
Which laboratory value is most important to monitor for a patient receiving heparin therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.