Nokea
Patient teaching for risk reduction of skin cancer should include
- A. Having suspicious moles checked by a dermatologist.
- B. Daily sun exposure every 1/2 hour.
- C. Daily sun exposure of 1 hour to build tolerance.
- D. Applying moisturizer.
Correct Answer: A
Rationale: Regular monitoring of moles and avoiding excessive sun exposure are vital for skin cancer prevention.
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The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
What is the best strategy for communicating with clients with Limited English Proficiency (LEP)?
- A. Ask a family member to translate.
- B. Request a telephonic interpreter.
- C. Request a certified interpreter.
- D. Ask a bilingual staff member to interpret.
Correct Answer: C
Rationale: Certified interpreters ensure accurate and culturally sensitive communication, minimizing errors and misunderstandings.
When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with another nonsurgical client
- C. A room in the ICU
- D. A room that is within view of the nurses' station
Correct Answer: A
Rationale: The correct answer is A: a room with air exhaust directly to the outdoor environment. This is to prevent the spread of tuberculosis to other patients and healthcare workers. Tuberculosis is an airborne disease, so proper ventilation is crucial. Choice B is incorrect as placing the client with another nonsurgical client may increase the risk of transmission. Choice C is not ideal as the ICU may have other vulnerable patients. Choice D is also incorrect as the proximity to the nurses' station does not address the need for proper ventilation to prevent the spread of tuberculosis.
What is contraindicated for a client being treated for Ménière’s disease?
- A. Alcohol
- B. Smoking
- C. A high-protein diet
- D. Cough syrups and other CNS depressants
Correct Answer: D
Rationale: CNS depressants can worsen dizziness and imbalance associated with Ménière’s disease.