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The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing?
- A. Apply a Kerlix roll and tape it to the skin.
- B. Apply a large, soft pad and tape it to the skin.
- C. Apply small Montgomery straps and tie the edges together.
- D. Apply a Kling roll and tape the edge of the roll onto the bandage.
Correct Answer: D
Rationale: Standard dressing technique includes the use of Kling rolls on circumferential dressings. With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps should not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway).
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During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?
- A. Weight gain
- B. Night sweats
- C. Severe lymph node pain
- D. Headache with minor visual changes
Correct Answer: B
Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
- A. Thyroid cancer
- B. Acute laryngitis
- C. Laryngeal cancer
- D. Bronchogenic cancer
Correct Answer: C
Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk?
- A. After the client eats lunch
- B. After the client has a brief nap
- C. After the client uses the metered-dose inhaler
- D. After assessing the client's oxygen saturation
Correct Answer: C
Rationale: The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore, this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, the respiratory status of the client may not be at its best. Although monitoring oxygen saturation is appropriate, the intervention itself does not affect the client's respiratory function.
A client has been taking a prescribed calcium channel blocker therapy for approximately 2 months. The home care nurse monitoring the effects of therapy should determine that drug tolerance has developed if which is noted in the client?
- A. Decrease in weight
- B. Increased joint pain
- C. Output greater than intake
- D. Gradual rise in blood pressure
Correct Answer: D
Rationale: Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. Joint pain is not associated with this form of tolerance.