Nokea
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
- A. Report the ulcer to the admitting care provider.
- B. Teach the man about STD prevention.
- C. Ask the man if he has a history of syphilis.
- D. Clean the ulcer; reporting is not necessary because an STD is unlikely in a man this age.
Correct Answer: A
Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.
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Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.
A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.