A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?

Notify the surgeon of the temperature elevation.

Encourage the client to drink more fluids.

Assess the surgical incision for signs of infection.

Monitor vital signs every 4 hr.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.

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Correct Answer is A

Explanation

the correct answer is Choice A.

Choice A rationale: Basal cell carcinoma (BCC) is a type of skin cancer that develops in basal cells, a type of cell within the skin that produces new skin cells 1.One of the common symptoms of BCC is a pearly white, skin-colored or pink bump 1.This can also appear as a shiny or pearly nodule with a smooth surface 2.Therefore, a pearly, waxy nodule is a characteristic lesion of basal cell carcinoma

Choice B rationale: An irregular border on a variegated-colored lesion is more commonly associated with melanoma, another type of skin cancer, rather than basal cell carcinoma 1.While BCC can have a variety of appearances, an irregular border on a variegated-colored lesion is not typically characteristic of BCC

Choice C rationale: A firm, nodular, crusty, or ulcerated lesion can be a sign of several types of skin conditions, including squamous cell carcinoma, another type of skin cancer 1.While BCC can sometimes appear as a firm nodule 1 , the description of a crusty or ulcerated lesion is not as characteristic of BCC as a pearly, waxy nodule

Choice D rationale: A weeping vesicle is not typically associated with basal cell carcinoma 1.BCC lesions are more likely to appear as a shiny bump or nodule, or a flat, scaly patch 1.A weeping vesicle could be indicative of a different skin condition

A. Poor skin turgor. B. Fruity breath odor. C. Kussmaul respirations. D. Irritability.

Correct Answer is D

Explanation

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

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A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?

Correct Answer is A

Explanation

A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Correct Answer is D

Explanation

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