An adult client comes to the clinic and reports concern over a lump that, "Just popped up on my neck about a week ago." While performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. Which of these findings suggest?

Lymphangitis.

Malignancy.

Viral Infection.

Bacterial Infection.

Answer and Explanation

The Correct Answer is B

A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.

B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.

C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.

D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B. Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C. Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D. Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.

Correct Answer is ["18"]

Explanation

First, we need to find the concentration of Heparin per milliliter in the current infusion. We can do this by dividing the total number of Heparin units by the total volume of the infusion:

Heparin concentration (units/mL) = Total Heparin units / Total volume (mL) Heparin concentration = 25,000 units / 500 mL

Heparin concentration = 50 units/mL

Now, we know the desired rate of Heparin delivery (900 units/hour) and the concentration of Heparin per milliliter (50 units/mL). We can use this information to calculate the required flow rate in milliliters per hour:

Flow rate (mL/hour) = Desired Heparin rate (units/hour) / Heparin concentration (units/mL)

Flow rate = 900 units/hour / 50 units/mL Flow rate = 18 mL/hour

Therefore, the nurse should set the infusion pump to deliver 18 mL/hour.

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Naxlex Comprehensive Predictor Exams

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

Correct Answer is ["18"]

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?