A community health nurse is teaching a group of clients about melanoma. Which of the following
characteristics of lesions associated with melanoma should the nurse include in the teaching?
A. One solid color
B. Symmetrical in shape
C. Less than 6mm in diameter
D. An irregular border - ANS - D
\A home health nurse enters a clients home and finds a used insulin syringe, without a cap, on
the table. Which of the following action should the nurse take?
A. Recap the needle on the syringe
B. Schedule a nurse to administer future injections for this client
C. Explain to the client that the syringe should be disposed of in the bathroom trash can
D. Place the syringe in a puncture proof disposal container - ANS - D
\A nurse in an emergency department is caring for a client who reports developing severe right
eye pain with a gritty sensation while sawing wood. Which of the following actions should the
nurse take first?
A. Instill proparacaine hydrochloride eyedrops
B. Perform ocular irrigation of the right eye
C. Place the client in a suspine position with the head turned toward the affected side
D. Ask the client about the first aid performed at the scene - ANS - D
\A nurse in an ER is assessing a client who has extensive burns, including on her face. Which of
the following assessments should the nurse perform first?
A. Estimation of burn injury
B. Characteristics of cough and sputum
C. Extent of peripheral edema
D. Amount of urine output - ANS - B
\A nurse in an ER is assessing a client who sustained a fall off a roof. Which of the following
findings should the nurse identify as an indication of a basilar skull fracture?
A. A depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp - ANS - B
The nurse should idenitfy cerebrospinal fluid, which appears as a clear fluid, coming from the
nares or ears as an indication of a basilar skull fracture
\A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of
the following findings should the nurse report to provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in left leg. - ANS - C
, \A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow
on the client for which of the following purposes?
A. Raising the bed linens off the clients feet to prevent plantar flexion
B. Keeping the clients heels off the bed to prevent pressure ulcers
C. Positioning the client off the operative site while in bed
D. Preventing dislocation of the hip during position changes or movement - ANS - D
\A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at
the bedside. Which of the following actions should the nurse take first?
A. Provide oxygen
B. Place the client in a side lying position
C. Provide privacy
D. Lower the client to the floor - ANS - D
\A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%.
Prior to initiating a transfusion of packed red blood cells, which of the following actions should
the nurse take? SATA
A. Assess and document the vitals
B. Restart the IV with a 22 G
C. Verify with another nurse the blood type and Rh of packed RBCs
D. Hang a bag of LR IV solution
E. Change IV tubing to set that has a filter - ANS - A C E
\A nurse is caring for a client who has continuous bladder irrigation following a transurethral
resection of the prostate (TURP). Which of the following findings should the nurse report to the
provider?
A. output equal to the instilled irrigant
B. Report of bladder spasms
C. Viscous urinary output with clots
D/ Report of a strong urge to urinate - ANS - C
The nurse should report urine output that is bright red with clots or urine that resembles ketchup
to the provider because this is an indication of arterial bleeding
\A nurse is caring for a client who has encephalitis due to west nile virus. Which of the following
actions should the nurse take? SATA
A. Place the client on respiratory isolation
B. Monitor vital signs every 2 hours
C. Assess neuro status every 4 hour
D. Maintain the client in a modified trendelenburg position
E. Keep the clients room darkened - ANS - B C E
\A nurse is caring for a client who has stage III pressure ulcer on the heel. When preparing to
irrigate the wound, which of the following actions should the nurse take first?
A. Obtain the prescribed irrigation solution
B. Don personal protective equipment
C. Check the clients pain level
D. Place a waterproof pad under the clients extremity - ANS - C
\A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the
following actions should the nurse take?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller phyliswambui996. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.99. You're not tied to anything after your purchase.
