Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure: The nurse is responsible for ensuring correct positioning to optimize visualization and safety during a sigmoidoscopy. Providing guidance or demonstration supports safe practice and enhances the PN’s competence.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: While additional assistance may be helpful, it does not address whether the client is positioned correctly, which is the immediate priority for procedural safety and effectiveness.

C. Assume care of the client and assign the PN to the care of a different client: Reassigning responsibilities may delay the procedure and does not utilize the opportunity for the PN to learn proper technique. Collaboration and teaching are preferred.

D. Acknowledge that the PN has positioned the client safely and correctly: Simply acknowledging the position without verifying or guiding may result in suboptimal visualization or risk to the client. The nurse must ensure accuracy rather than assume correctness.

Correct Answer is ["18"]

Explanation

Calculation:

Convert the client's weight from pounds (lb) to kilograms (kg).

The client's weight is 220 lb.

Client weight (kg) = 220lb/2.2lb/kg

= 100kg.

Calculate the total heparin dose to be administered per hour (units/hr).

The ordered rate is 18 units/kg/hour.

Total dose rate (units/hr) = 18units/kg/hour×100kg

= 1800units/hr.

Determine the concentration of the available solution (units/mL).

Available solution is 25,000units in 250mL.

Concentration (units/mL) = 25,000units/250mL

= 100units/mL.

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Totaldoserate(units/hr)/Concentration(units/mL)

= 1800units/hr/100units/mL

= 18mL/hr.

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Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is ["18"]

Explanation

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Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown