Nokea
When assessing a client's skin, the nurse notes a scattered red rash on the trunk. The individual lesions are about 0.5 cm in diameter and are flat, nonpalpable, and circumscribed. How would this type of lesion be classified?
- A. Papule
- B. Nodule
- C. Macule
- D. Patch
Correct Answer: C
Rationale: A flat, nonpalpable lesion ≤1 cm is a macule (C). Papules (A) are raised, nodules (B) are deeper and larger, and patches (D) are larger flat lesions.
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The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should
- A. place a trochanter roll on the outer aspect of the thigh.
- B. perform resistive range of motion of the left leg.
- C. adduct and internally rotate the left leg.
- D. instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield.
Correct Answer: B
Rationale: Voiding immediately before an IVP ensures the bladder is empty, improving visualization of the urinary tract.
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
- A. Complete blood count
- B. Clean-catch urinalysis
- C. Liver profile
- D. Thyroid function test
Correct Answer: C
Rationale: A liver profile is required before starting isotretinoin due to its potential hepatotoxicity, ensuring safe administration.
The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?
- A. Respirations 24, unlabored
- B. Urine output of 30 mL/hr
- C. Capillary refill <4 seconds
- D. Apical pulse of 110/min
Correct Answer: B
Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department as a robbery
- B. Report this behavior to the charge nurse
- C. Monitor the situation and note whether any items are missing
- D. Ignore the situation until items are reported missing
Correct Answer: B
Rationale: Reporting to the charge nurse ensures proper investigation.