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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. Obtain a prescription for regular insulin SUBQ per sliding scale. B. Record the blood glucose results and requisition a repeat test in one hour. C. Prepare to initiate a continuous IV infusion of Insulin in normal saline. D. Administer the client's daily metformin tablet with a sip of water.

Correct Answer is A

Explanation

Rationale:

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

A. Apply light pressure proximal to the IV site. B. Assess the radial pulse distal to the IV site. C. Assist the client to straighten the right arm. D. Elevate the client's right arm on one pillow.

Correct Answer is C

Explanation

Rationale:

A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.

B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.

C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.

D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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Correct Answer is A

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A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

Correct Answer is C

Explanation

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

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)]

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering 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?

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