Nokea
Which of the following should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply.
- A. Diminished hair on scalp and pubic areas.
- B. Dusky rubor of left lower extremity.
- C. Solar lentigo.
- D. Wrinkless.
- E. Yellow pigmentation.
Correct Answer: A,C,D
Rationale: Normal aging includes diminished hair, solar lentigo (age spots), and wrinkles. Dusky rubor suggests vascular issues, and yellow pigmentation may indicate jaundice, not normal aging.
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A client informs the nurse that she is using an herbal therapy while receiving chemotherapy. Which of the following actions should the nurse take?
- A. Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using.
- B. Guide the client in the decision-making process to select either Western or alternative medicine.
- C. Encourage the client to seek alternative modalities that do not require the ingestion of substances.
- D. Recommend that the client stop using the alternative medicines immediately.
Correct Answer: A
Rationale: Determining the herbal therapies used and informing the physician ensures safety, as some herbs can interact with chemotherapy drugs, affecting efficacy or toxicity.
The nurse has reinforced education at a conference on intramuscular (IM) injections. Which of the following statements by the participant would indicate a correct understanding of the teaching?
- A. "Aspiration before injection of IM medications is no longer universally recommended."
- B. "The deltoid muscle provides slower absorption rates than gluteal sites."
- C. "To ease a client's anxiety, inform the client that an IM injection will not hurt."
- D. "The dorsogluteal muscle is recommended as a site for IM injections."
Correct Answer: A
Rationale: Aspiration is not universally recommended for IM injections due to lack of evidence supporting its necessity.
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.
Which of the following findings would suggest pneumothorax in a trauma victim?
- A. Pronounced crackles.
- B. Inspiratory wheezing.
- C. Dullness on percussion.
- D. Absent breath sounds.
Correct Answer: D
Rationale: Absent breath sounds on the affected side suggest pneumothorax due to air in the pleural space. Crackles, wheezing, and dullness are more indicative of other conditions.