Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Instruct incentive spirometry use every hour.

Encourage consumption of protein and vitamin C.

Apply thromboembolism deterrent stockings (TED).

Use Petroleum based lotion on legs

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. While peppers and onions provide antioxidants, the presence of processed meat (ham) increases the risk of some cancers, particularly colorectal cancer, due to nitrates and preservatives.
B. Pancakes with blueberries and maple syrup, and a turkey sausage patty. Blueberries are rich in antioxidants, which can help reduce cancer risk, but pancakes with syrup are high in refined carbohydrates and added sugars, which may contribute to inflammation and increased cancer risk.
C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. Oatmeal contains fiber, which helps reduce the risk of colorectal cancer. Raisins and nuts provide antioxidants, while grapefruit is high in vitamin C, which supports immune function and may help protect against some cancers. This is the best balanced meal with cancer-protective nutrients.
D. Poached egg, bacon, biscuit, and canned peaches in light syrup. Bacon is a processed meat linked to an increased risk of colorectal cancer. Biscuits are refined carbohydrates, and canned peaches in syrup contain added sugars, which can contribute to inflammation and chronic disease risk.

A. Staphylococcus aureus abscess around a hair follicle. B. Insect or spider bite that becomes infected. C. Sexual contact with an infected partner. D. Inadequate blood supply to the area

Correct Answer is A

Explanation

A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.

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Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting a nutritional class on foods that have been linked to help decrease the development of some forms of cancer. Which meal selection is the best choice to help reduce the risk of some cancers?

Correct Answer is C

Explanation

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

Correct Answer is A

Explanation

Exhibits The nurse reviews the client's data. Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

A female client was horseback riding when her horse slipped and fell on her leg, crushing but not breaking it, and resulting in a large amount of edema over the crushed area. Which pathophysiological mechanism is responsible for the edema?

The nurse is teaching a health promotion class for adults about the effects of sun exposure on skin. Which statement about the function of collagen is correct?

Exhibits

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.