After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side
lying position. The nurse understands that the purpose of this intervention is to accomplish
which?
Limit bleeding from the biopsy site
Rationale:
After a liver biopsy, the client is assisted with assuming a right side-lying position with a small
pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit
bleeding from the biopsy site. The liver produces bile that flows through the common bile duct;
client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not
the purpose of the right side-lying position.
The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should
place the client in which position for insertion?
High-Fowler's position
Rationale:
Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's
position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be
placed behind the head and shoulders to promote the client's ability to swallow during procedure.
Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct
placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in
the stomach?
Placement is verified on x-ray.
Rationale:
The end of the NG tube should be in the stomach. An x-ray is the most reliable method of
determining correct placement. The radiologist may recommend moving the tube backward or
forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be
from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump
inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach.
Auscultation of the air injection is not recommended as a reliable method to establish correct
placement.
,A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a
nasogastric (NG) tube from the client. Which interventions should be included in the
procedure? Select all that apply.
2. Explain the procedure to the client.
3. Ask the client to take a deep breath and hold.
4. Pull the tube out in one continuous steady motion.
5. Remove the device or tape securing the tube from the nose.
Rationale:
Before removing the tube, the client should be told about the procedure and review the
instructions. The tape or securing device needs to be removed from the client's nose. When the
NG tube is removed, the client is instructed to take and hold a deep breath. This will close the
epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for
the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with
one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube.
An adult client was burned as a result of an explosion. The burn initially affected the client's
entire face (the anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire and the
client ran, which caused subsequent burn injuries of the posterior surface of the head and the
upper half of the posterior torso. According to the rule of nines, what is the extent of this client's
burn injury? Fill in the blank.
Correct Answer: 36 %
Rationale:
According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the
upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The
subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of
the posterior torso, which equals 9%. This totals 36%.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that
was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse
understands that which characteristics describe this type of a lesion? Select all that apply.
3. It is highly metastatic.
5. Lesion is a nevus that has changed in color.
Rationale:
Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the
epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a
person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the
,basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and
although metastasis is rare, underlying tissue destruction can progress to include vital structures.
Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by
local invasion and the potential for metastasis.
The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as
basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be
documented in the client's record? Select all that apply.
1. Lesion has a waxy border
2. An irregularly shaped lesion
Rationale:
Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A
melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color.
Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of
ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule
with a dry, rough, adherent yellow or brown scale.
The nurse reinforces instructions to a group of clients regarding measures that will assist with the
prevention of skin cancer. Which statement by a client indicates the need for further teaching?
"I need to avoid sun exposure before 10:00 am and after 4:00 pm."
Rationale:
The client should be instructed to avoid sun exposure between the hours of approximately 10:00
am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor
activities. The client should be instructed to examine the body monthly for the appearance of any
possible cancerous or precancerous lesions.
A client arrives at the emergency department and has experienced frostbite to the right hand.
What should the nurse expect to find when inspecting the client's hand?
A white color of the skin which is insensitive to touch
Rationale:
The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and
insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters
or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.
, The evening nurse reviews the nursing documentation in the client's chart and notes that the day
nurse has documented that the client has a stage 2 pressure injury in the sacral area. What
should the nurse expect to find when checking the client's sacral area?
Partial-thickness skin loss of the epidermis
Rationale:
With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the
epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow
crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs
during stage 3 and tunneling develops during stage 4.
The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding
should the nurse note if this disorder is present?
Silvery-white scaly lesions
Rationale:
Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red
macules with scales. The skin is dry and there is no presence of wheal patches scattered about
the trunk.
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for
a circumferential arm burn?
The return of distal pulses
Rationale:
Escharotomies are performed to alleviate the compartment syndrome that can occur when edema
forms under nondistensible eschar in a circumferential burn. Escharotomies are performed
through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is
considered a complication rather than an anticipated therapeutic outcome. The formation of
granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the
formation of edema.
The nurse is caring for a client with circumferential burns of both legs. Which leg position is
appropriate for this type of a burn?
Elevation above the level of the heart
Rationale:
Circumferential burns of the extremities may compromise circulation. Elevating injured
lying position. The nurse understands that the purpose of this intervention is to accomplish
which?
Limit bleeding from the biopsy site
Rationale:
After a liver biopsy, the client is assisted with assuming a right side-lying position with a small
pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit
bleeding from the biopsy site. The liver produces bile that flows through the common bile duct;
client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not
the purpose of the right side-lying position.
The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should
place the client in which position for insertion?
High-Fowler's position
Rationale:
Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's
position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be
placed behind the head and shoulders to promote the client's ability to swallow during procedure.
Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct
placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in
the stomach?
Placement is verified on x-ray.
Rationale:
The end of the NG tube should be in the stomach. An x-ray is the most reliable method of
determining correct placement. The radiologist may recommend moving the tube backward or
forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be
from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump
inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach.
Auscultation of the air injection is not recommended as a reliable method to establish correct
placement.
,A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a
nasogastric (NG) tube from the client. Which interventions should be included in the
procedure? Select all that apply.
2. Explain the procedure to the client.
3. Ask the client to take a deep breath and hold.
4. Pull the tube out in one continuous steady motion.
5. Remove the device or tape securing the tube from the nose.
Rationale:
Before removing the tube, the client should be told about the procedure and review the
instructions. The tape or securing device needs to be removed from the client's nose. When the
NG tube is removed, the client is instructed to take and hold a deep breath. This will close the
epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for
the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with
one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube.
An adult client was burned as a result of an explosion. The burn initially affected the client's
entire face (the anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire and the
client ran, which caused subsequent burn injuries of the posterior surface of the head and the
upper half of the posterior torso. According to the rule of nines, what is the extent of this client's
burn injury? Fill in the blank.
Correct Answer: 36 %
Rationale:
According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the
upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The
subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of
the posterior torso, which equals 9%. This totals 36%.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that
was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse
understands that which characteristics describe this type of a lesion? Select all that apply.
3. It is highly metastatic.
5. Lesion is a nevus that has changed in color.
Rationale:
Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the
epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a
person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the
,basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and
although metastasis is rare, underlying tissue destruction can progress to include vital structures.
Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by
local invasion and the potential for metastasis.
The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as
basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be
documented in the client's record? Select all that apply.
1. Lesion has a waxy border
2. An irregularly shaped lesion
Rationale:
Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A
melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color.
Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of
ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule
with a dry, rough, adherent yellow or brown scale.
The nurse reinforces instructions to a group of clients regarding measures that will assist with the
prevention of skin cancer. Which statement by a client indicates the need for further teaching?
"I need to avoid sun exposure before 10:00 am and after 4:00 pm."
Rationale:
The client should be instructed to avoid sun exposure between the hours of approximately 10:00
am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor
activities. The client should be instructed to examine the body monthly for the appearance of any
possible cancerous or precancerous lesions.
A client arrives at the emergency department and has experienced frostbite to the right hand.
What should the nurse expect to find when inspecting the client's hand?
A white color of the skin which is insensitive to touch
Rationale:
The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and
insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters
or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.
, The evening nurse reviews the nursing documentation in the client's chart and notes that the day
nurse has documented that the client has a stage 2 pressure injury in the sacral area. What
should the nurse expect to find when checking the client's sacral area?
Partial-thickness skin loss of the epidermis
Rationale:
With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the
epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow
crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs
during stage 3 and tunneling develops during stage 4.
The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding
should the nurse note if this disorder is present?
Silvery-white scaly lesions
Rationale:
Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red
macules with scales. The skin is dry and there is no presence of wheal patches scattered about
the trunk.
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for
a circumferential arm burn?
The return of distal pulses
Rationale:
Escharotomies are performed to alleviate the compartment syndrome that can occur when edema
forms under nondistensible eschar in a circumferential burn. Escharotomies are performed
through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is
considered a complication rather than an anticipated therapeutic outcome. The formation of
granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the
formation of edema.
The nurse is caring for a client with circumferential burns of both legs. Which leg position is
appropriate for this type of a burn?
Elevation above the level of the heart
Rationale:
Circumferential burns of the extremities may compromise circulation. Elevating injured
