Reduction of Risk Potential - ML6
A client who is black reports itching and rashes after consuming shellfish. On examination, the nurse finds a keloid on the client's back. What is the most appropriate action by the nurse? Inform the healthcare provider about it. Consider it as normal. Request biochemical investigations. Consider it as an allergic reaction to shellfish.
Answer: Consider it as normal. Explanation: The nurse should consider the appearance of keloids as normal in black clients. Keloids are irregular, elevated, thick scars found commonly in darker-skinned clients. Informing the healthcare provider or requesting biochemical investigations is inappropriate because this condition is not pathologic. Also, keloids are not the result of allergic reactions.
A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse? -"RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby." -"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." -"RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh positive baby." -"RhoGAM suppresses antibody formation in women with RH negative blood after giving birth to an Rh negative baby."
Answer: "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.
A 6-year-old child is being discharged from the emergency department after being diagnosed with varicella (chickenpox). The nurse knows the parents need more medication teaching when they state they will give the child which over-the-counter medication? ibuprofen aspirin acetaminophen naproxen
Answer: aspirin Explanation: The parents require additional teaching if they state they will give their child aspirin because using aspirin during a viral infection has been linked to Reye's syndrome, a serious illness that can lead to brain damage and death in children. If the child requires medication for fever or discomfort, the nurse should recommend acetaminophen or ibuprofen. Naproxen isn't indicated for the treatment of fever.
A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? jugular vein distention right upper quadrant pain bibasilar crackles dependent edema
Answer: bibasilar crackles Explanation: Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
The client with an above-the-knee amputation is to be fitted with a functioning prosthesis. The nurse has been teaching the client how to care for the residual limb. Which behavior would demonstrate that the client has an understanding of proper residual limb care? The client: applies powder to the residual limb. inspects the residual limb weekly with a mirror. removes the prosthesis whenever he sits down. washes and dries the residual limb daily.
Answer: washes and dries the residual limb daily. Explanation: Washing and thoroughly drying the residual limb daily are important hygiene measures to prevent infection. Nothing should be applied to the residual limb after it is cleansed. Powder may cause excessive drying and cracking of the skin, and cream may soften the skin excessively. The residual limb should be inspected daily with a mirror for early signs of skin breakdown. To reduce residual limb swelling, the prosthesis should be removed only at night.
