Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Proctosigmoidoscopy. A proctosigmoidoscopy is a screening test used to visualize the rectum and the lower part of the colon. It allows the physician to directly visualize any abnormalities, such as polyps or tumors, which can be indicators of colorectal cancer. This test is particularly useful in diagnosing colorectal cancer because it provides direct visualization of the affected area. Now, let's discuss why the other options are incorrect: A) Barium enema is a radiologic imaging test that can show the outline of the colon, but it is not as effective in directly visualizing abnormalities like polyps or tumors compared to a proctosigmoidoscopy. B) Carcinoembryonic antigen (CEA) is a blood test that measures the level of a protein that may be elevated in colorectal cancer, but it is not a screening test. It is used more for monitoring response to treatment and detecting cancer recurrence. C) Annual digital rectal examination is a physical exam where the physician inserts a gloved, lubricated finger into the rectum to feel for abnormalities. While this exam is important for detecting some colorectal abnormalities, it is not as comprehensive as a proctosigmoidoscopy. In an educational context, understanding the rationale behind choosing the correct screening test for colorectal cancer is crucial for nurses and healthcare providers. It ensures appropriate and timely diagnostic procedures are performed, leading to early detection and better patient outcomes. Regular review of screening guidelines and procedures helps healthcare professionals provide optimal care to patients at risk for colorectal cancer.

Correct Answer: B

Rationale: In the post-anesthesia care unit (PACU), maintaining a postoperative tonsillectomy and adenoidectomy (T and A) client in a prone position with the head on a pillow and turned to the side is crucial for several reasons. Placing the client in a prone position helps prevent aspiration of blood or secretions, as gravity aids in drainage. Additionally, this position promotes airway patency by allowing the tongue to fall forward, preventing obstruction. On the other hand, the other options are incorrect for various reasons. Option A, placing the client supine with the neck hyperextended and supported with a pillow, can increase the risk of airway obstruction due to potential obstruction of the pharynx by the tongue. Option C, placing the client in a semi-Fowler's position with the neck flexed, may also lead to airway compromise as neck flexion can obstruct the airway. Option D, placing the client in reverse Trendelenburg with an extended neck, does not provide the optimal positioning for airway management and can increase the risk of aspiration. In an educational context, understanding the rationale behind positioning postoperative clients is essential for nurses working in the PACU. Proper positioning can significantly impact patient outcomes, including airway patency, prevention of complications such as aspiration, and overall patient safety and comfort. Nurses must be knowledgeable about appropriate postoperative positioning techniques to provide high-quality care and ensure positive recovery outcomes for their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Dermis is partially damaged. Superficial partial-thickness burns involve damage to the epidermis and superficial layers of the dermis. This type of burn is characterized by redness, blistering, and pain. By selecting this option, the nurse accurately informs Sergio's wife that the burn has affected the outermost layer of skin and partially penetrated the dermis. Option A) Structures beneath the skin are damaged is incorrect because superficial partial-thickness burns do not typically extend beyond the dermis. Option C) Epidermis and dermis are both damaged is incorrect as it describes a full-thickness burn, not a partial-thickness burn like Sergio's. Option D) Epidermis is damaged is also incorrect as a superficial partial-thickness burn involves damage to both the epidermis and dermis. Educationally, understanding the depth and severity of burns is crucial for providing appropriate care and educating patients and their families. By accurately identifying the type of burn, healthcare providers can develop effective treatment plans and prevent complications. It is essential for nurses to be knowledgeable about burn classifications to ensure optimal patient outcomes.

Correct Answer: D

Rationale: In radiation therapy, the earliest sign of a skin reaction is pigmentation (Option D). This occurs due to the damage caused to melanocytes in the skin by the radiation. Pigmentation changes are often the first noticeable effect on the skin following radiation exposure. Erythema (Option B) typically occurs after pigmentation changes and is characterized by redness of the skin. Desquamation (Option A) refers to the shedding of the outer layers of the skin and usually occurs as a later stage reaction to radiation. Atrophy (Option C) is the thinning of the skin and is also a delayed effect of radiation exposure. Educationally, understanding the sequence of skin reactions to radiation therapy is crucial for nurses and healthcare providers involved in caring for patients undergoing radiation treatment. Recognizing these signs early can help in providing timely interventions to manage and alleviate the skin reactions, thus improving the patient's overall comfort and treatment experience.

Correct Answer: C

Rationale: In the event of an adverse hemolytic reaction during a blood transfusion, the correct nursing intervention should focus on stopping the infusion, calling the physician, and assessing the client (Option C). This is the correct answer because a hemolytic reaction can be life-threatening and requires immediate action to prevent further harm to the patient. Option A is incorrect because simply slowing the infusion may not be sufficient to address the serious nature of a hemolytic reaction. Calling the physician and assessing the patient are important steps, but stopping the infusion is crucial. Option B is incorrect because sending the remaining blood to the laboratory is not a priority when the client's safety is at risk. Stopping the infusion and assessing the client should take precedence. Option D is incorrect because in the case of a hemolytic reaction, just slowing the infusion and keeping a patent IV line open for medication administration is not enough. The priority is to stop the infusion and address the adverse reaction promptly. From an educational perspective, understanding the importance of immediate action in the face of a potentially life-threatening situation like a hemolytic reaction during a blood transfusion is crucial for nurses. This scenario emphasizes the significance of rapid assessment, critical thinking, and prioritization in providing safe and effective patient care in clinical practice.