Nokea
The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as:
- A. Negative.
- B. Needing to be repeated.
- C. Positive.
- D. False.
Correct Answer: C
Rationale: A positive tuberculin skin test (induration ‰¥10 mm in most cases) indicates exposure to Mycobacterium tuberculosis. Without the figure, the context suggests a positive result based on typical test interpretation.
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? Select all that apply.
- A. Purchase sunscreen containing benzophenoness to check UVA and UVB rays.
- B. Use sunscreen with a minimum of 15 sun protection factor (SPF).
- C. Obtain genetic screening to identify risk of melanoma.
- D. Apply sunscreen only on sunny days, especially between 10 AM and 2 PM.
- E. Have a pigmented lesion biopsied by shaving if it looks suspicious.
- F. Rub baby oil to lubricate skin before going out in the sun.
Correct Answer: A,B
Rationale: Sunscreen with benzophenones and SPF 15 or higher protects against UVA/UVB rays. Genetic screening is not routine, sunscreen should be used daily, shave biopsies are inappropriate, and baby oil increases UV damage.
The nurse is teaching a client about managing osteoarthritis pain. Which non-pharmacologic intervention should be included?
- A. Apply ice packs for 30 minutes at a time.
- B. Maintain a high-protein diet.
- C. Use a heating pad on high setting.
- D. Perform gentle range-of-motion exercises.
Correct Answer: D
Rationale: Gentle range-of-motion exercises maintain joint mobility and reduce stiffness in osteoarthritis.
A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, 'When will my strength return?' Which of the following responses by the nurse is most appropriate?
- A. Your fatigue should be gone by now. We will evaluate you for a secondary infection.
- B. Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete.
- C. It is important for you to increase your activity level. That will help decrease your fatigue.
- D. It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months.
Correct Answer: D
Rationale: Fatigue is common during recovery from hepatitis A and typically resolves in 2-4 months (D). Secondary infection (A) is not indicated. Fatigue is not drug-related (B), and increasing activity prematurely (C) may worsen symptoms.
The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?
- A. timolol
- B. hydroxyzine
- C. phenylephrine
- D. imipramine
Correct Answer: A
Rationale: Timolol, a beta-blocker, reduces intraocular pressure in angle-closure glaucoma by decreasing aqueous humor production. Hydroxyzine, phenylephrine, and imipramine are not used for this condition.