NCLEX-PN Test #9 3 Flashcards

The PN is assessing a skin lesion using the ABCDE rule. A lesion has irregular borders, multiple colors (brown, black, and pink), and a diameter of 8 mm. What action should the nurse take?

Answer: Refer the client to a dermatologist for evaluation of possible melanoma

The ABCDE rule for melanoma screening: Asymmetry, Border irregularity, Color variation, Diameter > 6 mm, Evolution. This lesion has three major warning signs (B, C, D). Any suspicious lesion must be evaluated by a dermatologist for biopsy. Early detection is critical as melanoma is highly curable when caught early.

A client with full-thickness burns covering 20% of their body surface area (BSA) is admitted. Using the Parkland formula, what volume of lactated Ringer's solution should be infused in the first 8 hours?

Answer: 3,200 mL (assuming 80 kg weight)

Parkland formula: 4 mL × kg × % BSA burned = total volume in 24 hrs. For an 80 kg client with 20% BSA: 4 × 80 × 20 = 6,400 mL total. Half (3,200 mL) is given in the first 8 hours post-burn (not post-admission), and the remaining 3,200 mL over the next 16 hours.

A client is prescribed ophthalmic eye drops. In which area should the nurse instill the drops to minimize systemic absorption?

Answer: Lower conjunctival sac (lower cul-de-sac)

Eye drops should be instilled into the lower conjunctival sac (formed by gently pulling down the lower eyelid) to minimize corneal trauma and reduce drainage through the nasolacrimal duct (which leads to systemic absorption). Nasolacrimal occlusion by pressing on the inner canthus for 1–2 minutes further reduces systemic absorption.

The PN is teaching a client with psoriasis about management. Which statement by the client indicates correct understanding?

Answer: "Stress can trigger flare-ups, so managing stress is an important part of my care."

Psychological stress is a well-documented trigger for psoriasis flares because stress activates immune pathways that stimulate keratinocyte proliferation. Stress management is a key component of psoriasis care. Moderate UV exposure actually improves psoriasis (phototherapy is a treatment). Psoriasis is an autoimmune condition, not infectious.

A client reports sudden loss of vision in one eye with painless, dense curtain-like shadow. What complication does the nurse suspect?

Answer: Retinal detachment

Retinal detachment presents with sudden painless vision loss described as a "curtain" or "veil" descending over the visual field, preceded by floaters and flashes of light (photopsia). This is an ophthalmic emergency requiring immediate ophthalmology referral. Glaucoma causes painful vision loss with halos around lights.

The nurse is caring for a client with hearing loss who uses hearing aids. Which nursing action best facilitates communication during care?

Answer: Ensure the hearing aids are in place before beginning client education; speak facing the client in a quiet environment

For clients with hearing aids, effective communication requires: ensuring aids are in and functioning, facing the client directly (facilitates lip reading), speaking at a normal pace and volume in a quiet environment, using short sentences, and confirming understanding. Shouting distorts speech sounds and is counterproductive.