Answers | Latest Update | Exam Prep Guide
1. A nurse is collecting data from a client who has systemic scleroderma. what
should the nurse expect?
alopecia
periorbital edema
excessive salivation
skin tightening
2. Describe why color variation within a skin lesion is significant in the ABCDE
method for skin cancer screening.
No change in appearance indicates that the lesion is not concerning.
Color variation within a lesion may indicate malignancy and is a
warning sign in the ABCDE method.
Small size is always a positive sign and does not need further
evaluation.
Uniform color suggests a benign condition and does not require
reporting.
3. If a nurse finds that the urinary drainage bag is full but there is no drainage,
what should the nurse do next after assessing for obstruction?
Call for a urologist to evaluate the situation.
Change the catheter to a larger size.
Empty the drainage bag and re-assess for urine output.
Administer diuretics to increase urine output.
,4. If a client expresses concerns about the risks associated with TURP, how
should the nurse respond to demonstrate understanding and provide
reassurance?
The nurse should dismiss the concerns as unimportant.
The nurse should only focus on the benefits of the procedure.
The nurse should suggest the client avoid the procedure altogether.
The nurse should explain the common risks and how they are
managed during the procedure.
5. DURING THE EARLY EMERGENT (RESUSCITATIVE) PHASE OF BURN INJURY,
THE PATIENT'S LABORATORY RESULTS WOULD MOST LIKELY BE?
↓ Hct, ↓ serumalbumin, ↓serumNa, ↑ serumK+
↑ Hct, ↓serumNa, ↑ serumK+
↑ Hct, ↓serumNa, ↓ serumK+
↓ Hct, ↑ serumNa, ↑ serumK+
6. When caring for a client that is undergoing allergy skin testing, the nurse
must:
observe the client for 1 hour following the skin test.
have emergency equipment and drugs available.
use only latex-free equipment.
prepare the skin of the client's upper arms for testing.
7. What discharge instructions should the nurse give a client with a new
diagnosis of myasthenia gravis (MG)?
how to protect the sacral area from breakdown
, complementary therapies to help manage pain
possible need for splenectomy to help control symptoms.
measures to help avoid fatigue and undue stress
8. If a client expresses concern about their ability to communicate after a total
laryngectomy, what supportive action should a healthcare provider take?
Inform them that they will need to learn sign language only.
Provide information on alternative communication methods.
Reassure the client that their voice will return.
Suggest they avoid speaking altogether.
9. Why is it important for a nurse to monitor for specific findings after restarting
TPN therapy?
To monitor for side effects of oral nutrition.
To assess the effectiveness of oral medications.
To evaluate the client's mental status.
To ensure the client is tolerating the therapy and to prevent
complications.
10. If a patient presents with severe swelling and pain after a rattlesnake bite,
what should the nurse prioritize in their care plan?
Administering antivenom as prescribed
Applying ice to the affected area
Prescribing oral pain medication
Monitoring vital signs only
, 11. Why is it important for a nurse to assess for obstruction in the urinary
drainage system after a TURP?
To evaluate the effectiveness of the TURP procedure.
To monitor the patient's vital signs.
To ensure proper urine flow and prevent complications.
To determine the need for a catheter replacement.
12. Why is it important for a nurse to assess the patient's airway and breathing
immediately after removing an endotracheal tube?
To check the patient's vital signs.
To ensure that the patient can breathe adequately and that there
are no complications.
To prepare for the next procedure.
To provide emotional support to the patient.
13. If a postmenopausal client has a BMI of 32 and has been on hormonal
replacement therapy for 10 years, what recommendations should the nurse
provide to manage her breast cancer risk?
Encourage weight management and discuss alternatives to
hormonal therapy.
Suggest increasing her hormonal therapy dosage.
Recommend a high-calcium diet without any lifestyle changes.
Advise her to stop all physical activity.
14. What is one key finding a nurse should monitor after restarting TPN therapy?
Dehydration