While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

Apply lubricating lotion to the areas.

Refer the client for a skin lesion biopsy.

Ask about recent international travel.

Record the presence of senile lentigines.

Answer and Explanation

The Correct Answer is D

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

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Correct Answer is C

Explanation

A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.

A. Place the vial with the remainder of the medication into a locked drawer. B. Ask another nurse to witness the medication being discarded. C. Withdraw the medication into a syringe and label it with the client's name. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is B

Explanation

A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.
B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.
C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.
D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?