Nokea
Which common ailment should the nurse instruct the client who underwent a stapedectomy to immediately report to the physician?
- A. The common cold
- B. A sore throat
- C. A productive cough
- D. Conjunctivitis
Correct Answer: A
Rationale: A cold can lead to middle ear pressure changes, risking surgical complications.
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The nurse in a dermatology clinic is taking the history of a client. Which questions should the nurse ask the client? Select all that apply.
- A. When did you first notice the skin problem?
- B. What cosmetics or skin products do you use?
- C. Have you experienced any loss of sensation?
- D. What is your current and previous occupation?
- E. Do you experience any itching, burning, or tingling?
Correct Answer: A,B,C,D,E
Rationale: All listed questions assess onset, triggers, symptoms, and occupational exposures, critical for dermatologic history.
On inspecting the client's eye, the nurse will note which symptom of conjunctivitis in addition to erythema?
- A. Dried drainage along the eyelid
- B. Lack of pupil response to light
- C. Bulging of the eye from the orbit
- D. Loss of moisture on the cornea
Correct Answer: A
Rationale: Conjunctivitis often presents with dried, crusty drainage along the eyelid.
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.