Nokea
The client has just had a basal cell carcinoma removed in the doctor's office. Which statement the client makes indicates understanding regarding prevention and early detection of basal cell carcinoma?
- A. Moles that are round and brown should be seen immediately by my doctor.'
- B. I should wear long sleeves when I am out in the sun.'
- C. I should avoid using lotions and powders on my skin.'
- D. I can use a tanning booth to get a tan since I can't stay in the sun very long.'
Correct Answer: B
Rationale: Long sleeves protect against UV exposure, a key risk for basal cell carcinoma. Moles, lotions, or tanning booths are unrelated or harmful.
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While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.
A 5-year old is admitted to the hospital with pneumonia. Her orders include chest physiotherapy, mist tent, and inhalation with Mucomyst (acetylcysteine). Which of the following measures should be included in her care?
- A. Telling her to breathe in through her nose and breathe out through her mouth
- B. Applying lotion to the exposed parts of her body
- C. Checking her clothing and linen frequently for dampness
- D. Obtaining a rectal temperature q 4 hours
Correct Answer: C
Rationale: Checking clothing and linen for dampness is necessary due to the mist tent, which can cause moisture buildup, leading to discomfort or skin issues.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.8 mEq/L) is a serious complication of spironolactone, a potassium-sparing diuretic, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.