NCLEX Daily Ten Question Practical Exercise 8

6. In a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-year-old patient who is scheduled for elective surgery and has a notably hairy forearm where the I.V. is to be placed. The patient is allergic to a variety of adhesives and has sensitive skin that is prone to irritation. Given these considerations, how should the nurse manage excess hair at the intended catheter insertion site?

A. Leaving the hair intact

B. Shaving the area

C. Clipping the hair in the area

D. Removing the hair with a depilatory

E. Applying a small amount of water-soluble gel to tame the hair without cutting

F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible without causing abrasions

Correct Answer: C

Answer Explanation:

Clipping is preferred over shaving in this scenario because it reduces the potential for creating microabrasions that can increase infection risk, which is especially important in a patient with sensitive skin. Chemical depilatories (D) are not recommended due to the patient’s history of allergies and sensitive skin. Leaving the hair intact (A) could interfere with the securement of the I.V. and increase the risk of infection. Water-soluble gel (E) is not standard practice for managing hair at an I.V. site and does not address the infection control issue. A sterile surgical scalpel (F) is not typically recommended for hair removal in preparation for I.V. insertion due to the risk of cuts and abrasions. Clipping is the safest option that balances the need to reduce infection risk with the patient’s sensitivity and allergy concerns.

7. A nurse is tasked with the education of an elderly female patient who has been recently diagnosed with osteoporosis. The patient leads a sedentary lifestyle, has a diet low in calcium, has undergone menopause ten years prior, and has a visibly kyphotic posture. In planning the education for this patient, which of the following complications should the nurse emphasize as the most significant risk associated with osteoporosis, especially considering the patient’s profile?

A. Increased susceptibility to bone fractures from minimal trauma

B. Consequences of long-term estrogen deficiency post-menopause

C. The impact of sustained negative calcium balance on bone density

D. The progression of spinal deformities such as a kyphotic curvature

E. Potential for height loss over time due to vertebral compression

F. Risk of developing chronic pain associated with skeletal weakness

Correct Answer: A

Answer Explanation:

Given the patient’s diagnosis of osteoporosis, a sedentary lifestyle, and poor dietary habits, the most significant and immediate complication is the risk of bone fractures, particularly hip, wrist, and spine fractures, which can result from minimal stress. The patient’s visible kyphosis also indicates a history of spinal bone loss, which compounds this risk. Estrogen deficiency (B) is a contributing factor to the development of osteoporosis but is not a direct complication. Negative calcium balance (C) is a concern that should be addressed as it contributes to bone density loss; however, it is not a complication but rather a contributing factor. Progression of spinal deformities (D), height loss (E), and chronic pain (F) are all concerns associated with osteoporosis. Still, the priority education should focus on preventing fractures, which can have immediate and severe consequences on the patient’s mobility and quality of life.

8. A community health nurse is conducting a workshop on breast health for a group of women with diverse backgrounds, ranging from those who have never performed Breast Self-Examination (BSE) to some who have had benign breast conditions in the past. As part of the educational session, the nurse emphasizes the importance of BSE for the early detection of potential breast anomalies. What should the nurse identify as the primary goal for these women in performing regular BSE?

A. To detect any cancerous lumps early in their development

B. To identify areas of thickness or fullness that differ from the rest of the breast tissue

C. To notice any changes in the breast tissue from what is normal for each individual

D. To differentiate between fibrocystic masses and other types of breast lumps

E. To promote self-awareness of breast health and encourage routine health screening

F. To understand the normal texture and appearance of their breast tissue for future comparison

Correct Answer: C

Answer Explanation:

The primary purpose of BSE is for individuals to become familiar with their own breasts so they can detect any changes early, which could be indicative of breast cancer or other breast conditions. Detecting cancerous lumps (A) is an important aspect of BSE, but the emphasis is on noticing any change, not only cancer. Identifying areas of thickness or fullness (B) and differentiating types of masses (D) are part of noticing changes, but these are not the primary goals. Promoting self-awareness and encouraging routine screening (E), as well as understanding normal breast tissue (F), are also critical educational points, but the main goal remains the detection of any new or unusual changes since the last examination.

9. A nurse is managing the care of a 32-year-old female client diagnosed with hyperthyroidism. The client reports experiencing palpitations, unintentional weight loss, and intermittent bouts of excessive sweating. The treatment plan includes antithyroid medications. In addition to administering medication, what nursing interventions should be prioritized to manage the client’s condition best?

A. Ensure the client is provided with extra blankets and clothing to maintain a warm environment due to heightened sensitivity to cold.

B. Closely monitor the client for increased signs of restlessness, sweating, and significant weight loss.

C. Create a balance between the client’s periods of activity and rest to manage fatigue without exacerbating symptoms.

D. Encourage increased physical activity to counteract the sedative effects of the medication and prevent constipation.

E. Regularly check the client’s temperature as they are prone to developing fevers.

F. Offer a low-iodine diet and coordinate with a dietitian to manage dietary influences on thyroid function.

Correct Answer: C

Answer Explanation:

Clients with hyperthyroidism may experience symptoms like fatigue and muscle weakness. Balancing activity with rest helps to conserve energy and prevent exacerbation of symptoms.

Option A: Providing extra blankets is more associated with patients with hypothyroidism.
Option B: Monitoring for signs of restlessness and sweating is essential, but this option refers more to the assessment of potential overmedication rather than an intervention.
Option D: Encouraging the client to be active to prevent constipation (D) is less specific to hyperthyroidism, where diarrhea is more common than constipation.
Options E and F: Checking for fever (E) and offering a low-iodine diet (F) are additional supportive measures. However, they do not directly address managing the client’s current symptoms and treatment plan as effectively as balancing activity and rest.

10. A nurse is providing discharge education to a 55-year-old client who has been hospitalized with symptoms leading to a diagnosis of atherosclerosis. The client has a sedentary lifestyle, a high-stress job, and a diet high in saturated fats. As part of the client’s comprehensive care plan to manage and reduce the progression of atherosclerosis, which of the following lifestyle modifications should the nurse emphasize?

A. Emphasize the importance of not focusing solely on weight as a health measure, but rather on overall cardiovascular health.

B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as walking or swimming.

C. Advise adherence to a heart-healthy diet, rich in fruits, vegetables, whole grains, and lean proteins, while limiting saturated fats and cholesterol.

D. Counsel on stress management techniques and the importance of incorporating relaxation activities into daily routines.

E. Discuss smoking cessation strategies if applicable and avoid exposure to secondhand smoke.

F. Suggest regular monitoring of blood pressure and cholesterol levels with follow-up appointments to assess cardiovascular health.

Correct Answer: B

Answer Explanation:

Increasing physical activity is a key intervention for a client with atherosclerosis in managing and slowing the disease’s progression. While the other options are valid health measures, they are less directly impactful on atherosclerosis than increasing physical activity. A heart-healthy diet (C) and stress management (D) are also essential but support the primary intervention of increased physical activity. Smoking cessation (E) is critical if the client smokes, and regular monitoring (F) is part of ongoing management, but these options were not specified in the original question.

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