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While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

Apply lubricating lotion to the areas.

Refer the client for a skin lesion biopsy.

Ask about recent international travel.

Record the presence of senile lentigines.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.

B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.

C. Recent international travel is unrelated to the development of senile lentigines.

D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

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A. White blood cell count of 6,000/mm3 (6 x 109/L). B. Decreased blood urea nitrogen. C. Hearing has decreased. D. Reports of photophobia.

Correct Answer is C

Explanation

Rationale:

A. A WBC count within the normal range does not indicate an adverse effect of gentamicin.

B. Gentamicin is more likely to increase BUN levels due to nephrotoxicity rather than decrease them.

C. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, which can lead to hearing loss. Decreased hearing is a significant adverse effect that should be promptly addressed.

D. Photophobia is not a common side effect of gentamicin.

A. Coronary artery bypass procedure was performed in 1995. B. Colonoscopy performed for routine screening six months ago. C. Digoxin and furosemide daily since 1996. D. Suffered with depression following death of spouse in 1999.

Correct Answer is C

Explanation

Rationale:

A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.

B. A recent colonoscopy is not relevant to the client's current symptoms.

C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.

D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

Correct Answer is C

Explanation

An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

Correct Answer is C

Explanation

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

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