Nokea
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
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Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.
In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? The client will:
- A. Have normalized albumin levels.
- B. Return to ideal body weight.
- C. Gain 1 lb every 2 weeks.
- D. Maintain current weight.
Correct Answer: D
Rationale: Maintaining current weight is a realistic goal for a client with advanced liver cancer and poor nutrition, as weight gain or normalized albumin may be unachievable due to disease progression.
A client with cancer is admitted with suspected disseminated intravascular coagulation (DIC). Which laboratory finding supports this diagnosis?
- A. Prolonged prothrombin time (PT).
- B. Elevated hemoglobin.
- C. Normal platelet count.
- D. Decreased D-dimer.
Correct Answer: A
Rationale: DIC causes abnormal clotting and bleeding, leading to a prolonged prothrombin time (PT) due to consumption of clotting factors, supporting the diagnosis.
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
- A. To support the lower portion of the leg.
- B. To support the thigh and upper leg.
- C. To allow attachment of the skeletal pin.
- D. To prevent flexion deformities in the ankle and foot.
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
- A. Apples.
- B. Tomato juice.
- C. Whole wheat bread.
- D. Beef tenderloin.
Correct Answer: B
Rationale: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.