Category: Uncategorized

A home health nurse is teaching a 66-year-old client and family caregiver about wound care for a surgical incision following removal of a skin lesion 5 days ago. The incision is closed with sutures, has minimal serous drainage, and edges are approximated. The client will perform dressing changes at home. Which instructions should the nurse include? (Select all that apply.)

A nurse is developing a care plan for a 44-year-old client with breast cancer receiving doxorubicin and cyclophosphamide chemotherapy. The client completed cycle 1 three weeks ago and is scheduled for cycle 2 today. Labs: WBC 6,400/uL, ANC 3,200/uL, Hgb 12.1 g/dL, platelets 165,000/ìL. Which nursing interventions are appropriate? (Select all that apply.)

A nurse is reviewing acid-base regulation with a nursing student. Which statements about renal buffering mechanisms are accurate? Select all that apply.

A nurse is providing discharge teaching to a transgender male client who is starting testosterone therapy. The client asks, “When will I start seeing changes?” Three months later, the client returns for follow-up and reports cessation of menses and increased facial hair. The client states, “I thought I’d see more changes by now. Should I increase my dose?” Which response by the nurse demonstrates accurate understanding of gender affirming hormone therapy?

A nurse is completing a cultural self-assessment to examine how personal background may influence care delivery. Which reflections indicate the nurse understands how cultural background affects nursing practice? Select all that apply.

A nurse is providing education to nursing students about caring for gender diverse clients. Which statements by the students demonstrate accurate understanding of biologic sex, gender identity, and sexual orientation? Select all that apply.

A client nearing the end of life begins creating a memory book for their grandchildren as a way to leave behind a legacy. Which dimension of psychosocial manifestation does this represent?

A nurse is caring for two clients who both rate their pain as 7 out of 10. The first client, who is in active labor, declines pain medication and states, “This pain means I’ll meet my baby soon-I can handle it.” The second client, experiencing chronic back pain for 2 years, states, “This pain controls my life and no one believes it’s real.” Which principle should guide the nurse’s individualized pain management approach for these clients?

A nurse is caring for a 52-year-old client with C5 spinal cord injury sustained 10 days ago. The client is on bedrest with a halo vest and requires total care. During morning assessment, the nurse identifies a 2 cm × 2 cm area on the right heel with intact skin, purple discoloration, and the area feels boggy to palpation. Which clinical manifestations are consistent with this presentation? (Select all that apply.)

A nurse is planning pressure injury prevention for a 58-year-old client with acute ischemic stroke affecting the left side. The client has right-sided weakness, requires assistance with all repositioning, and has a Braden Scale score of 15. Current position is supine. Vital signs: BP 168/94 mm Hg, HR 78 bpm, RR 16 breaths/min, T 98.2°F (36.8°C). Which interventions should the nurse include? (Select all that apply.)