Nokea
The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?
- A. Inserts the needle, bevel up at a 15-degree angle
- B. Instructs the client that the test will be read in 48-72 hours
- C. Selects a site 3 to 4 finger widths below the antecubital space
- D. Administers the test using a 20-gauge needle, 2 inches long
Correct Answer: D
Rationale: A PPD test requires a 26- or 27-gauge needle, 1/2 inch long, for intradermal administration.
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The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of:
- A. Aortic aneurysm
- B. Deep vein thrombosis (DVT) in the left leg
- C. I.V. drug abuse
- D. Intermittent claudication
Correct Answer: B
Rationale: Left leg pain, positive Homans' sign (pain on dorsiflexion), and low-grade fever suggest deep vein thrombosis (DVT). Further assessment for swelling, redness, or warmth confirms this. Aortic aneurysm, I.V. drug abuse, and claudication present differently.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
- A. Peripheral edema.
- B. Ascites.
- C. Anorexia.
- D. Jaundice.
Correct Answer: D
Rationale: Jaundice (D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (A) and ascites (B) occur later. Anorexia (C) is less specific.
The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply.
- A. Fatigue.
- B. Unexplained weight loss with adequate nutritional intake.
- C. Rectal bleeding.
- D. Bowel changes.
- E. Positive fecal occult blood testing.
Correct Answer: A,B,C,D,E
Rationale: Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer, and blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic. CN: Health promotion and maintenance; CL: Create
Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
- A. Wear a patch over one eye.
- B. Place personal items on the sighted side.
- C. Lie in bed with the unaffected side toward the door.
- D. Turn the head from side to side when walking.
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.