Nokea
During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
- A. An uneven shape
- B. A uniformly colored lesion
- C. A lesion that is small and flat
- D. A lesion that is less than 1 cm in diameter
Correct Answer: A
Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.
You may also like to solve these questions
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?
- A. 11,000 units.
- B. 13,000 units.
- C. 15,000 units.
- D. 17,000 units.
Correct Answer: A
Rationale: To calculate the total amount of heparin received, multiply the infusion rate (50 ml/hour) by the total infusion time (5.5 hours). This results in 275 ml of the solution infused. Since there are 20,000 units of heparin in 500 ml, there are 800 units per ml. Therefore, 275 ml contains 220,000 units. However, the heparin is diluted in 500 ml, so the client has received half of this amount, which is 110,000 units. Therefore, the correct answer is 11,000 units. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.
A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?
- A. Moves the patient's arm in a full circle.
- B. Moves the patient's arm across the body as far as possible.
- C. Moves the patient's arm behind the body, keeping the elbow straight.
- D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.
Correct Answer: D
Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.
What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?
- A. Elevate the head of the bed to 30-45 degrees.
- B. Check residual volumes every 4 hours.
- C. Verify tube placement every shift.
- D. Flush the tube with water every 4 hours.
Correct Answer: A
Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Carry a client's soiled linens out of the room in a mesh linen bag
- B. Place a client who has tuberculosis in a room with negative-pressure airflow
- C. Provide disposable plates and utensils for a client who is HIV-positive
- D. Dispose of a client's blood-saturated dressing in a biohazard bag
Correct Answer: B
Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.
During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?
- A. Calf swelling
- B. Elevated blood pressure
- C. Decreased urine output
- D. Generalized rash
Correct Answer: A
Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.