While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?

Correct Answer: A

Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.

Correct Answer: B

Rationale: Metabolic acidosis is a condition characterized by a low pH (acidemia) and a low plasma bicarbonate concentration. In this condition, the body either produces too much acid, kidneys cannot remove enough acid, or there is a bicarbonate loss. This leads to an excess of hydrogen ions in the body, resulting in a decrease in pH and bicarbonate levels. Respiratory acidosis, on the other hand, is characterized by a low pH and a high carbon dioxide concentration. Respiratory alkalosis is characterized by a high pH and a low carbon dioxide concentration. Metabolic alkalosis is characterized by a high pH and a high bicarbonate concentration.

Correct Answer: C

Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.

Correct Answer: B

Rationale: Aldosterone is a hormone produced by the adrenal glands that plays a crucial role in regulating the balance of sodium and potassium in the body. One of its primary functions is to retain sodium in the body, leading to increased reabsorption of sodium in the kidneys. This retention of sodium helps to maintain blood pressure and fluid balance. In contrast, other hormones like antidiuretic hormone (ADH) primarily regulate water reabsorption, while thyroid hormone and insulin do not have a direct role in retaining sodium in the body.

Correct Answer: A

Rationale: If a clotted cannula is aggressively flushed, there is a risk that the clot may break apart and enter the circulation. This can lead to serious complications such as embolism, where the clot travels through the blood vessels and blocks blood flow to vital organs. It is important to handle clotted cannulas with care to prevent such complications from occurring.