A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

Correct Answer: A

Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.

Correct Answer: B

Rationale: The correct answer is B because nipple discharge and a breast nodule are classic signs of breast cancer. Nipple discharge can be bloody or clear, and a breast nodule is a lump that feels different from the surrounding tissue. Fever (choice A) is not a common sign of breast cancer. Breast changes during menstruation (choice C) are normal hormonal fluctuations. Fever and erythema of the breast (choice D) are more indicative of an infection rather than breast cancer. Therefore, choice B is the most relevant sign of breast cancer among the options provided.

Correct Answer: D

Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being. Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.

Correct Answer: D

Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.

Correct Answer: A

Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding. Summary: B: Isolation to prevent infection - This is not related to the client's lab values. C: Seizure precautions - Not relevant to the client's lab values. D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.

Correct Answer: D

Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.

Correct Answer: D

Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time. Explanation for other choices: A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs. B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains. C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.

Correct Answer: B

Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.

Correct Answer: C

Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.