Nokea
How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
- A. Abnormal skin color changes in a client with dark skin cannot be determined
- B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
- C. The lips and mucus membranes of a client with dark skin are dusky in color
- D. Cyanosis in a client with dark skin is seen in the sclera
Correct Answer: C
Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.
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Which structures are located in the subcutaneous layer of the skin?
- A. Sebaceous and sweat glands
- B. Melanin and keratin
- C. Sensory receptors and hair follicles
- D. Adipose cells and blood vessels
Correct Answer: D
Rationale: The correct answer is D: Adipose cells and blood vessels. The subcutaneous layer, also known as the hypodermis, primarily consists of adipose (fat) tissue and blood vessels. Adipose tissue provides insulation, energy storage, and cushioning, while blood vessels supply nutrients and oxygen. Sebaceous and sweat glands are located in the dermis, which is the layer beneath the epidermis. Melanin and keratin are components of the epidermis, responsible for skin color and waterproofing, respectively. Sensory receptors and hair follicles are found in the dermis and extend into the subcutaneous layer but are not exclusive to it.
What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct Answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
What is the primary function of neutrophils?
- A. Heparin secretion
- B. Transport oxygen
- C. Phagocytotic action
- D. Antibody formation
Correct Answer: C
Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.
The nurse is assessing a client who has been receiving total parenteral nutrition (TPN) for several days. Which complication should the nurse monitor for?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hyponatremia
- D. Hypokalemia
Correct Answer: B
Rationale: The correct answer is B: Hypoglycemia. When a client is receiving total parenteral nutrition (TPN) with a high glucose content, the risk of hypoglycemia is significant due to sudden increases in insulin release in response to the glucose load. The nurse should monitor for signs and symptoms of hypoglycemia such as shakiness, sweating, palpitations, and confusion. Hyperglycemia (choice A) is not typically a complication of TPN as the high glucose content is more likely to cause hypoglycemia. Hyponatremia (choice C) and hypokalemia (choice D) are electrolyte imbalances that can occur in clients receiving TPN, but hypoglycemia is the more common and immediate concern that the nurse should monitor for.
The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse's priority action?
- A. Slow the rate of infusion
- B. Apply a warm compress to the site
- C. Discontinue the IV infusion
- D. Elevate the affected arm
Correct Answer: C
Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.