Nokea
The female client admitted for an unrelated diagnosis asks the nurse to check her back because 'it itches all the time in that one spot.' When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?
- A. Notify the HCP to check the lesion on rounds.
- B. Measure the lesion and note the color.
- C. Apply lotion to the lesion.
- D. Instruct the client to make sure the HCP checks the lesion.
Correct Answer: B
Rationale: Measuring and documenting the lesion provides baseline data for HCP evaluation. Notification, lotion, or client instruction are secondary.
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What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
- A. To prevent the deadly complication of aspiration
- B. To make the client more comfortable
- C. To help prevent paralytic ileus
- D. To help prevent excessive fluid loss
Correct Answer: C
Rationale: Severe burns predispose clients to paralytic ileus due to stress and fluid shifts, so keeping the client NPO prevents complications until bowel function returns.
The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client?
- A. Contact the health-care provider immediately for an appointment.
- B. Tell the client this is a normal aging change and no action should be taken.
- C. Tell the client to discuss this with the HCP at the next appointment.
- D. Have the client buy a wart remover kit at the store.
Correct Answer: C
Rationale: Rough, greasy papules may indicate seborrheic keratosis, requiring HCP evaluation at the next visit. Immediate visits, dismissing as normal, or OTC wart removers are inappropriate.