Which area in dark-skinned individuals would be the most likely to show a skin cancerous lesion?
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Solution
Answer D is correct. The palms of the hands and soles of the feet are areas in darkskinned clients where skin cancer is more likely to develop because of the decreased pigmentation found in these areas. Answers A, B, and C are areas where high pigmentation occurs and, therefore, are less likely to show signs of cancer.
Which clinical manifestation during a bone marrow transplant alerts the nurse to the possibility of an adverse reaction?
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Solution
Answer D is correct. Shortness of breath signifies an adverse reaction to the transplant procedure. Answers A and C can occur with the transplant process but do not signify an adverse reaction. Answer B is a normal finding with the bone marrow transplant.
A client is admitted with benign prostatic hypertrophy. Which clinical manifestation should the nurse expect?
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Solution
Answer A is correct. The person with benign prostatic hypertrophy (BPH) has clinical manifestations that are caused by the obstruction. Symptoms of BPH include frequency of urination, difficulty in starting the urine flow, and a frequent urge to void. If the client develops a urinary tract infection, the urine might smell, but it is not directly related to the BPH, so answer B is incorrect. Urinary retention also occurs, making answer C incorrect. Pain with urination is not a symptom of BPH, so answer D is incorrect.
Which medication should the nurse have available in case a client has an anaphylactic reaction to penicillin G benzathine (Bicillin)?
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Solution
Answer A is correct. Epinephrine, antihistamines, and resuscitation equipment should be available in case of a reaction to penicillin. Epinephrine is used for allergic reactions. Answer B is an antianxiety agent, and answer D is used for high blood pressure. The anti-ulcer agent in answer C is not used for allergic reactions.
A client is admitted after a motor vehicle accident. The nurse suspects that the client is in the compensatory stage of shock due to which clinical manifestations?
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Solution
Answer A is correct. When a person is in the compensatory stage of shock, the BP remains within normal limits. Increased heart rate occurs that allows cardiac output to be maintained. The client also exhibits confusion and cold and clammy skin. Answer B correlates with the progressive stage of shock, so it is incorrect. Answers C and D both indicate that the client is past compensation, so they are incorrect.
A client arrives after a house fire. What clinical manifestation is most indicative of possible carbon monoxide poisoning?
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Solution
Answer C is correct. The hallmark symptom of carbon monoxide poisoning is the cherry-red color. The answers in A, B, and D are not specific to carbon monoxide poisoning.
The nurse working on a surgical unit would identify which client as having the highest risk for pulmonary complications after surgery?
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Solution
Answer B is correct. The risk factors for pulmonary complications increase with abdominal surgery for clients over age 40, and for those with prolonged periods in bed. Answer B includes two risk factors, an age of more than 40 years and abdominal surgery in an area under the diaphragm. Answers A and C have one risk factor each, which makes them incorrect. Answer D involves a risk factor for deep vein thrombosis, so it is incorrect.
A client has a vagal nerve stimulator in place to prevent seizures. Which would indicate that the device is working properly?
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Solution
Answer A is correct. A vagal nerve stimulator is inserted surgically to treat seizure activity. If the device is working properly, the client will notice a voice change when the device is active. Answers B, C, and D don’t occur with the operation of the device, which makes them incorrect.
The nurse is preparing a client with cirrhosis for a paracentesis. How will the nurse position the client for this procedure?
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Solution
Answer D is correct. Placing the client in the sitting position for a paracentesis is recommended. The side-lying and head-down positions in answers A, B, and C are not recommended for a paracentesis.
A client has an order to remove the nasogastric tube. Which is the correct nursing action to remove the tube?
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Solution
Answer D is correct. The nurse should also ask the client to hold his breath to prevent aspiration, which is the correct procedure for discontinuing an NG tube. Clean gloves should be used for this procedure, making answer A incorrect. The tube should be removed continuously without pause, so answer B is incorrect. An amount of 30mL of air—not normal saline—can be inserted before removal, so answer C is incorrect.