Nokea
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
- A. I should keep the site clean and dry.
- B. If the site becomes red, I will notify my doctor.
- C. I should pump the port daily to maintain patency.
- D. The port will need to be flushed with saline to maintain patency.
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.
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A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
- A. 5 mm/hr
- B. 12 mm/hr
- C. 28 mm/hr
- D. 40 mm/hr
Correct Answer: D
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
- A. Massaging the reddened areas
- B. Performing range of motion exercises
- C. Administering antithrombotics as ordered
- D. Feeding the client a high-carbohydrate diet
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
A 28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce?
- A. The Apgar score is 11.
- B. The Apgar score is 9.
- C. The Apgar score is 6.
- D. The Apgar score is 4.
Correct Answer: B
Rationale: The Apgar score assesses appearance, pulse, grimace, activity, and respiration, with a maximum of 10. Bluish hands indicate acrocyanosis, common in newborns, deducting 1 point from appearance, resulting in a score of 9 if other parameters are normal. Option A is impossible, and C and D are too low for a healthy baby.
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
- A. Ask the client to raise the forearm above the head.
- B. Have the client spread all of the fingers wide and resist pressure.
- C. Ask the client to move the thumb toward the palm and then back to the neutral position.
- D. Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers.
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.
A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?
- A. I should use a mouthwash at least once a week.
- B. I should use warm saline or water to rinse my mouth.
- C. I should brush my teeth and rinse my mouth once a day.
- D. Increasing the amount of red meat in my diet will keep this from recurring.
Correct Answer: B
Rationale: To minimize the occurrence of oral thrush in a client with AIDS, maintaining good oral hygiene is essential. Rinsing the mouth with warm saline or water helps keep the oral cavity clean and reduces the risk of Candida overgrowth. Using mouthwash once a week is insufficient, and brushing only once a day does not provide adequate oral hygiene. Increasing red meat intake does not directly affect thrush prevention, as dietary changes unrelated to sugar or carbohydrate reduction have little impact on Candida infections.