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Questions 158

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Question 1 of 5

A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:

Correct Answer: C

Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.

Question 2 of 5

Which actions should be utilized prior to performing a tub bath on the 80 year-old client?

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Correct Answer: B, D

Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (
B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (
D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (
A) risks burns, and maintaining water flow pressure (
C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.

Question 3 of 5

A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:

Correct Answer: A

Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.

Question 4 of 5

The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:

Correct Answer: B

Rationale: Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. The estrogen-progesterone assay test is used to identify present tumors being fed from an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.

Question 5 of 5

A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

Correct Answer: B

Rationale: When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.

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