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?
A pearly, waxy nodule.
An irregular border on a variegated-colored lesion.
A firm, nodular, crusty, or ulcerated lesion.
A weeping vesicle.
The Correct Answer is A
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 cells1. One of the common symptoms of BCC is a pearly white, skin-colored or pink bump1. This can also appear as a shiny or pearly nodule with a smooth surface2. 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 carcinoma1. 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 cancer1. While BCC can sometimes appear as a firm nodule1, 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 carcinoma1. BCC lesions are more likely to appear as a shiny bump or nodule, or a flat, scaly patch1. A weeping vesicle could be indicative of a different skin condition
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.
Choice B rationale:
Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.
Choice C rationale:
Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.
Choice D rationale:
Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.
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