Nokea
The client asks the nurse to look at a lesion on the client’s body. Which characteristics should prompt the nurse to consider that the client may have a basal cell carcinoma (BCC)?
- A. Nodular in appearance, depression in the center, and has a “pearly” characteristic
- B. Irregular color, surface, and border, less than one centimeter, and appears eroded
- C. Dry, hyperkeratotic scaly-like papule and has the appearance similar to a wart
- D. Vesiculopustular lesion with a thick, honey-colored crust and pruritic in nature
Correct Answer: A
Rationale: BCC is nodular and ulcerative. Clinical manifestations include small, slowly enlarging papule; borders are translucent or “pearly” with overlying telangiectasia; erosion, ulceration, and depression of center. B. Clinical manifestations of malignant melanoma (not BCC) include irregular color, surface, and border; variegation of color including red, white, blue, black, gray, brown; flat or elevated; eroded or ulcerated. C. Actinic keratosis (not BCC) is characterized by being horny and “wartlike.” D. Impetigo is characterized by thick, honey-colored crusts and is treated with antibiotics and topical treatment.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which task should the nurse delegate to the UAP?
- A. Check on the bowel movements of a client diagnosed with melena.
- B. Take the vital signs of a client who received blood the day before.
- C. Evaluate the dietary intake of a client who has been noncompliant with eating.
- D. Shave the client diagnosed with severe hemolytic anemia.
Correct Answer: B
Rationale: Taking vital signs post-transfusion (B) is within UAP scope. Checking melena (A), evaluating diet (C), and shaving with anemia (D) require nursing judgment due to bleeding risks.
The client diagnosed with leukemia has received a bone marrow transplant. The nurse monitors the client’s absolute neutrophil count (ANC). What is the client’s neutrophil count if the WBCs are 2.2 (x103/mm3), neutrophils are 25%, and bands are 5%?
Correct Answer: 660
Rationale: ANC = WBC × (neutrophils% + bands%). WBC = 2,200/mm3, neutrophils = 25%, bands = 5%. ANC = 2,200 × (0.25 + 0.05) = 2,200 × 0.3 = 660/mm3.
The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client?
- A. Prednisone, a glucocorticoid.
- B. Zithromax, an antibiotic.
- C. Ativan, a tranquilizer.
- D. Epogen, a biologic response modifier.
Correct Answer: D
Rationale: Epogen (D) stimulates RBC production for autologous donation. Prednisone (A), Zithromax (B), and Ativan (C) are unrelated.
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The client who is receiving doxorubicin for the first time to treat multiple myeloma develops flushing, facial swelling, headache, chills, and back pain. Which statement made by the nurse is best?
- A. “These symptoms usually resolve in 1 day and are limited to the first dose.”
- B. “These are signs of toxicity; you may want to consider refusing treatment.”
- C. “I can give you ondansetron prescribed prn now to alleviate these symptoms.”
- D. “Side effects occur with chemotherapy, but focus on your cancer being cured.”
Correct Answer: A
Rationale: A. This response is best. The nurse informs the client correctly that the symptoms of doxorubicin (Adriamycin) are limited to the first dose. B. The nurse is providing unsolicited advice. C. Ondansetron (Zofran) is an antiemetic and will not alleviate all of the symptoms. D. This response belittles the client’s symptoms. There is no cure for multiple myeloma. Treatment will control the illness and maintain the client’s level of functioning for several years or more.