A nurse is caring for a client who states he has a nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should recognize that these findings are consistent with which of the following medical diagnoses?

Malignant melanoma

Basal cell carcinoma

Squamous cell carcinoma

Kaposi's sarcoma

Answer and Explanation

The Correct Answer is A

Choice A reason: Malignant melanoma is a type of skin cancer that often presents as a mole that changes in size, color, and appearance. The description of the lesion being dark brownish-black with irregular borders is characteristic of malignant melanoma. This type of cancer can metastasize rapidly and requires prompt medical intervention for diagnosis and treatment.

Choice B reason: Basal cell carcinoma typically appears as a pearly or waxy bump, often with visible blood vessels. It is less likely to present as a dark, irregularly bordered lesion. Basal cell carcinoma is generally slow-growing and less likely to change rapidly in size and color compared to malignant melanoma.

Choice C reason: Squamous cell carcinoma often presents as a red, scaly, and thickened patch on the skin, sometimes with a crusted or ulcerated surface. While it can change in size, it does not typically appear as a dark, irregularly bordered lesion. Squamous cell carcinoma usually develops in areas of the skin exposed to the sun and has a different presentation compared to malignant melanoma.

Choice D reason: Kaposi's sarcoma presents as purplish, reddish-blue, or dark brown lesions that are often flat or slightly raised. These lesions are common in clients with AIDS but are usually smaller and less likely to have irregular borders compared to malignant melanoma. The description provided is more consistent with malignant melanoma than Kaposi's sarcoma.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.

Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.

Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.

Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.

Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.

A. "I took a laxative yesterday." B. "I took my metformin before breakfast." C. "I haven't had anything to eat or drink since last night." D. "The last time I voided it was painful."

Correct Answer is B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

Correct Answer is B

Explanation

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following client behaviors should alert the nurse that the client is having difficulty adjusting to the loss of her breast?

A nurse is planning care for several clients and is considering the clients’ risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

A nurse at an outpatient surgery center is reinforcing discharge teaching with a client’s partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. After administering high-flow oxygen, which of the following actions is the nurse’s highest priority?

A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

A nurse is assisting in the planning of care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse recommend including in the plan of care?