A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blister like lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

Correct Answer: D

Rationale: The correct answer is D: Vesicles. Vesicles are small, elevated lesions filled with clear fluid, typically less than 0.5 cm in diameter. In this case, the client's presentation of elevated, round, blister-like lesions filled with clear fluid matches the description of vesicles. Pustules (A) are similar in appearance but contain pus, while papules (B) are raised, solid lesions without fluid-filled cavities. Plaques (C) are flat, raised lesions typically larger than 1 cm in diameter. Therefore, based on the specific characteristics of the lesions described in the scenario, the appropriate term to use would be vesicles.

Correct Answer: A

Rationale: The correct answer is A: A 79 year-old malnourished client on bed rest. This client is at highest risk for decubitus ulcers due to malnourishment causing poor tissue healing, and immobility leading to pressure ulcers. The other choices are less likely: B may have increased pressure but obesity does not directly correlate with ulcer risk, C's incontinence may increase risk of skin breakdown but not as high as malnutrition and immobility, and D's ambulatory status reduces the risk compared to bed rest.

Correct Answer: A

Rationale: The correct answer is A: Supine position with a pillow. Placing the client in a supine position with a pillow helps prevent post-lumbar puncture headache by aiding in the restoration of normal cerebrospinal fluid pressure. The pillow supports the head and neck, reducing strain on the puncture site. Choice B: Supine with neck hyperextended is incorrect as it can increase the risk of complications and discomfort for the client. Choice C: Prone for 24 hours is incorrect as it can lead to increased pressure on the puncture site and hinder the recovery process. Choice D: Orthopneic is incorrect as this position is typically used for respiratory distress and not indicated post-lumbar puncture.

Correct Answer: B

Rationale: The correct answer is B, lower abdomen. Securing the catheter tubing in the lower abdomen helps prevent dislodgment by reducing movement and tension on the catheter. This area allows for easy monitoring of the catheter site and minimizes the risk of accidental removal. Taping the catheter tubing on the inner thigh or lower thigh may lead to increased friction and movement, increasing the risk of dislodgment. Choosing "All of these" is incorrect because taping the catheter tubing in multiple areas can cause unnecessary discomfort and potential complications for the client.

Correct Answer: C

Rationale: The correct answer is C: Droplet isolation precaution. This is because droplet precautions are used to prevent the spread of infectious agents that are transmitted through respiratory droplets. In this scenario, the client must wear a surgical mask when outside the room to prevent the spread of droplets containing pathogens to others. A: Airborne precautions are used for pathogens that can be transmitted through the air over long distances, such as tuberculosis. B: Contact precautions are used for direct contact with the client or their environment to prevent the spread of pathogens. D: Standard precautions are used for all clients to prevent the spread of infection through contact with blood, body fluids, or contaminated surfaces.