Question

A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Generalized rash.

Rationale :

🩸Toxic shock syndrome (TSS) is a rare but life-threatening condition often caused by Staphylococcus aureus producing toxins, commonly associated with tampon use or surgical wounds.

🌡️A generalized rash is a classic symptom of TSS, typically appearing as a diffuse, sunburn-like erythematous rash that later desquamates, especially on the palms and soles.

💉The condition often includes fever, hypotension, multi-organ involvement, and mucous membrane hyperemia, which help distinguish it from other febrile illnesses.

🧬Findings like elevated platelet count or decreased bilirubin are not hallmark features, and in fact, platelets may be normal or low due to systemic inflammation and DIC risk.

📌Core message

Generalized rash is a key clinical feature of toxic shock syndrome due to toxin-mediated systemic response and helps differentiate it from other causes of fever and hypotension.

Answer 2

Correct Answers:

"l apply a lubricating lotion to the cracked areas on the soles of my feet every morning.•.

Rationale :

🧴Peripheral arterial disease (PAD) causes decreased perfusion, making skin on the lower extremities dry and prone to breakdown.

🔥Applying lubricating lotion helps maintain skin integrity and prevent cracks, which can be entry points for infection.

⚠️However, lotion should be applied carefully — not between toes — to avoid maceration and fungal growth.

🚫The other options (soaking in hot water, heating pads, or elevating legs) can worsen ischemia or cause injury due to impaired sensation and poor circulation.

📌Core message

Use moisturizers to protect fragile skin in PAD while avoiding practices that impair circulation or cause injury.

Answer 3

Correct Answers:

Dark red granulation tissue.

Rationale :

🌹The presence of dark red granulation tissue indicates healing and tissue regeneration in a pressure ulcer.

🧲It reflects new capillary growth, fibroblast activity, and collagen deposition, which are hallmarks of the proliferative phase.

🧪Yellow exudate may indicate infection, and dry brown eschar typically reflects necrotic or unstageable wounds.

✅Firm wound tissue is not a reliable indicator of healing and may instead reflect fibrosis or unresolved inflammation.

📌Core message

Dark red granulation tissue is a reliable indicator of healing and tissue repair in pressure ulcers.

Answer 4

Correct Answers:

Administer 0.9% sodium chloride.

Rationale :

💉In diabetic ketoacidosis (DKA), fluid resuscitation is the first and most critical intervention to treat hypovolemia and restore perfusion.

🧪Hyperglycemia causes osmotic diuresis, leading to severe fluid and electrolyte losses.

⚠️While insulin is essential, it should only be administered after initial rehydration has started, as insulin therapy without volume support can worsen hypokalemia and shock.

🔋Bicarbonate therapy is controversial and reserved for severe acidosis (pH <6.9).

📌Core message

The priority in DKA is to begin fluid resuscitation with isotonic saline to correct dehydration and support perfusion.

Answer 5

Correct Answers:

"l should expect less than 25 mL of secretions per day in the drainage devices.".

Rationale :

🩺After a modified radical mastectomy with breast expander placement, small amounts of serosanguinous drainage are expected.

📉A decreasing output of <25 mL per day suggests that wound healing is progressing appropriately and that the drain can be considered for removal.

💪Using heavy weights or keeping the arm flexed continuously can impair recovery and increase lymphedema risk.

🕒Expansion of the prosthesis usually begins 2–3 weeks post-op, not 2 months, depending on wound healing.

📌Core message

Low drainage volume is a key indicator of healing progress after mastectomy and expander placement.

Answer 6

Correct Answers:

Hold breaths tor about 3 to 5 seconds before exhaling.

Rationale :

🎈The goal of the incentive spirometer is to promote deep lung inflation and prevent atelectasis.

📌Instructing the client to inhale slowly and hold their breath for 3 to 5 seconds allows alveolar expansion and gas exchange, reducing the risk of post-op pneumonia.

📏Placing the mouthpiece in the mouth, not at a distance, is essential for proper use.

🌫️Exhaling through pursed lips and placing hands on the abdomen are techniques more appropriate for COPD or breathing exercises.

📌Core message

Proper use of an incentive spirometer includes breath-holding to enhance alveolar expansion and gas exchange.

Answer 7

Correct Answers:

Colonics.

Rationale :

🚫Colonics, also known as colon cleansing or hydrotherapy, involve the infusion of fluid into the colon to flush out contents and are contraindicated in diverticulitis due to the risk of bowel perforation.

⚠️Clients with diverticulitis have inflamed and weakened intestinal walls, which can rupture with increased intraluminal pressure.

🌿Other therapies like acupuncture, saw palmetto, and guided imagery do not pose direct GI mechanical risks.

🧘The nurse must assess the safety of complementary therapies in the context of the patient's condition.

📌Core message

Colonics are contraindicated in diverticulitis due to risk of perforation from increased intestinal pressure.

Answer 8

Correct Answers:

"Wash your perineal area two times each day with antimicrobial soap.".

Rationale :

🧽Clients with chemotherapy-induced immunosuppression are at high risk for infection, particularly from mucosal and perineal bacteria.

🧴Using antimicrobial soap twice daily helps reduce bacterial load and prevent infection in this vulnerable area.

🚫Other options like washing a toothbrush monthly or changing water every 4 hours are not adequate infection prevention measures.

🐾Handling pet litter should be avoided entirely due to risk of toxoplasmosis or other infections.

📌Core message

Antimicrobial hygiene practices in perineal areas are essential to prevent infection in immunocompromised clients.

Answer 9

Correct Answers:

Consult the client before approaching the dog.

Rationale :

👩‍⚕️Service animals are working companions and not pets; it is critical to show respect by asking the handler before interacting with the dog.

🔕Touching, feeding, or commanding the dog without permission can distract it from its duties, potentially putting the client at risk.

💬Respecting the autonomy of the client and their service animal is a demonstration of therapeutic communication and professional boundaries.

🐾Providing water or giving commands without consent also crosses professional lines.

📌Core message

Respecting client autonomy means consulting before interacting with a service animal to maintain safety and professionalism.

Answer 10

Correct Answers:

Insert a large-bore nasogastric tube.

Rationale :

🧪In upper GI bleeding, such as from a peptic ulcer, inserting a large-bore NG tube allows for aspiration, lavage, and monitoring of bleeding.

🔍This provides diagnostic information, decompresses the stomach, and helps reduce aspiration risk.

💉Ketorolac is contraindicated due to risk of worsening bleeding.

💊Nitroprusside is for hypertensive emergencies and not related here.

🧴A 22-gauge IV line is too small for rapid fluid or blood replacement, which may be necessary in acute GI bleeding.

📌Core message

Use of a large-bore NG tube is essential for managing and evaluating upper GI bleeding in acute cases.

1 :
A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

2 :
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching.

3 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

4 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

5 :
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assessing a client who has a new diagnosis of diverticulitis and reports that he uses multiple complementary and alternative healing therapies. Which of the following complementary therapies should the nurse identify as contraindicated for the client?

8 :
A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

9 :
A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

10 :
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?

1 : A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

2 : A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching.

3 : A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

4 : A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

5 : A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is assessing a client who has a new diagnosis of diverticulitis and reports that he uses multiple complementary and alternative healing therapies. Which of the following complementary therapies should the nurse identify as contraindicated for the client?

8 : A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

9 : A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

10 : A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?

1 :
A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

2 :
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching.

3 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

4 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

5 :
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assessing a client who has a new diagnosis of diverticulitis and reports that he uses multiple complementary and alternative healing therapies. Which of the following complementary therapies should the nurse identify as contraindicated for the client?

8 :
A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

9 :
A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

10 :
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?