Patient Data

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided.

The nurse recognizes that a diagnosis of
dropdown
explained by assessment findings of
dropdown
and
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"B"}

Rationale:

• Cellulitis: The client presents with redness, warmth, swelling, and tenderness in the left lower leg, which are hallmark signs of cellulitis. The history of a small cut from shaving provides a portal of entry for bacterial infection. The acute onset over several days and localized inflammation support a diagnosis of cellulitis rather than vascular or neuropathic causes.

• Left lower leg erythema: Erythema is a key clinical indicator of inflammation and infection in cellulitis. The asymmetry between legs and localized redness around the ankle and foot highlights the affected area. Combined with swelling and warmth, erythema supports the diagnosis and guides monitoring for progression.

• Break in skin: The presence of a small scab or cut provides a pathway for bacterial entry, explaining the localized infection. Skin trauma is a common predisposing factor for cellulitis, especially in clients with diabetes or peripheral vascular disease. Identification of the break is important for understanding etiology and planning treatment.

• Deep vein thrombosis: Although DVT can cause unilateral leg swelling and pain, it usually does not produce erythema that is warm and localized near a small cut. The client also has no risk factors like recent immobilization or sudden onset swelling in this case. Assessment findings favor an infectious cause rather than thrombotic obstruction.

• Intermittent claudication: Intermittent claudication causes pain in the legs during exertion due to peripheral arterial disease, but it does not present with redness, warmth, or localized swelling. The client’s pain is associated with leg tightness and erythema, not exertion-related ischemia. Vascular compromise is not the primary concern here.

• Hyperglycemia: While the client’s blood glucose of 252 mg/dL is elevated, hyperglycemia alone does not explain the localized leg redness, swelling, and warmth. Hyperglycemia may contribute to poor healing and increased infection risk, but it is not the cause of the acute leg findings.

• Capillary refill greater than 3 seconds: Prolonged capillary refill indicates peripheral perfusion delay but does not specifically diagnose cellulitis. It may reflect underlying vascular disease or edema, but the primary indicators of cellulitis are erythema and skin break.

• Pain: 2 on a 0 to 10 scale, bilateral lower legs described from neuropathy: The mild, bilateral neuropathic pain is chronic and unrelated to the acute infection in the left leg. It does not support a diagnosis of cellulitis, which is characterized by localized pain and tenderness at the infection site.

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Correct Answer is B

Explanation

Rationale:
A. Microwave oven: Microwaves do not generate electromagnetic interference strong enough to affect a pacemaker. The client can safely use a microwave without risk to the device’s function.

B. Security wand: Hand-held security wands used in airports or some buildings can emit electromagnetic fields that may interfere with pacemaker function. The client should avoid prolonged or close exposure and notify security personnel about the pacemaker.

C. Toaster: Household appliances such as toasters generate minimal electromagnetic interference and are safe for clients with pacemakers. Normal use does not affect device operation.

D. Electric blanket: Modern electric blankets produce low-level electromagnetic fields that are generally considered safe for pacemaker recipients. Brief, standard use does not interfere with pacemaker function.

A. Sterile specimen cup. B. Examination gloves. C. Normal saline solution. D. Needleless 10 mL syringe. E. Drainage container.

Correct Answer is ["B","E"]

Explanation

Rationale:
A. Sterile specimen cup: A sterile cup is used for collecting urine for culture or diagnostic testing, not for routine measurement of urinary output. Measuring total output does not require sterility.

B. Examination gloves: Gloves are essential to maintain standard precautions and protect the nurse from contact with urine, which may contain pathogens. They are required for safe handling of urinary drainage systems.

C. Normal saline solution: Saline is not needed for routine measurement of urinary output from an ileal conduit. It is only used for irrigation if prescribed or if a blockage occurs.

D. Needleless 10 mL syringe: A syringe is not required to measure total urinary output. Syringes are used only for accessing ports or collecting small samples, not for emptying a drainage bag.

E. Drainage container: A calibrated container is necessary to collect and measure urine accurately from the ileal conduit. It allows quantification of urinary output, which is critical for monitoring fluid balance.

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Patient Data Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of dropdown explained by assessment findings of dropdown and dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is being discharged after implantation of a permanent pacemaker. The client should be instructed to avoid which item?

Correct Answer is B

Explanation

When preparing to measure urinary output from a client's ileal conduit, which item(s) should the nurse bring to the room? Select all that apply.

Correct Answer is ["B","E"]

Explanation

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Patient Data The nurse is considering the client's presentation and which information must be shared with a healthcare provider (HCP). Click to highlight the condition(s) that the nurse should share with the healthcare professional.

Patient Data 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.

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. Which teaching should the nurse provide?"

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

A male client informs the nurse he has suddenly stopped taking the glucocorticoid medication without consulting the healthcare provider. The nurse should recognize the client is at risk for developing which condition?

Patient Data

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided.

The nurse recognizes that a diagnosis of
dropdown
explained by assessment findings of
dropdown
and
dropdown
.