A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?

Skin tags noted in the neck region

A change in appearance of a mole on the shoulder

Atrophic wart on the left index finger

A flat, nonpalpable, discolored area of skin on the trunk

Answer and Explanation

The Correct Answer is B

Choice A reason:
Skin tags noted in the neck region: Skin tags are generally benign and not typically a cause for immediate concern. While they can be removed if desired, they are not as urgent as assessing potential changes in moles for skin cancer.
Choice B reason:
A change in appearance of a mole on the shoulder is the appropriate answer. The nurse's priority should be a change in the appearance of a mole on the shoulder. Changes in the colour, size, shape, or texture of a mole can indicate potential skin cancer, especially malignant melanoma. Timely assessment and appropriate follow-up are crucial to catch any skin cancer early and ensure effective treatment.
Choice C reason:
The atrophic wart on the left index finger is incorrect. An atrophic wart is a benign skin condition and is not typically associated with skin cancer or immediate danger. It may not require urgent assessment.
Choice D reason:
A flat, nonpalpable, discoloured area of skin on the trunk: While any change in skin appearance should be assessed, a nonpalpable, discoloured area may not present an immediate concern unless it shows signs of growth, change, or other concerning features.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

a small amount of serosanguineous drainage,

Lung sounds are diminished in posterior lobes,

pain as 8 on a scale of 0 to 10,

Blood pressure 168/84 mm Hg

A. A blood glucose level of 110 mg/dl. B. Diarrhea one time in a 24-hr period C. A weight gain of 0.91 kg (2 lb) in 2 days D. A gastric residual of 300 mL at the end of the shift

Correct Answer is C

Explanation

Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.

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A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

Correct Answer is C

Explanation

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