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A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
- A. Insert a nasogastric (NG) tube.
- B. Ask the client about the precipitating events.
- C. Obtain vital signs.
- D. Complete a head-to-toe assessment.
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
- A. Red skin with edema in the nail beds.
- B. Black fingertips surrounded by an erythematous rash.
- C. A white appearance to the skin that is insensitive to touch.
- D. A pink edematous hand.
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (Choice A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (Choice B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (Choice D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
- C. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- D. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
Correct Answer: C
Rationale: Correct Answer: C - The catheter will be used to compress the plaque against the coronary blood vessel wall.
Rationale: During a PTCA procedure, a balloon-tipped catheter is used to compress the plaque against the vessel wall, widening the artery lumen and improving blood flow. This process does not involve cutting away the plaque or taking pressure measurements. Option A is incorrect as the catheter does not spring open but rather compresses the plaque. Option B is incorrect as the catheter is not used for pressure measurements. Option D is incorrect as there is no embedded blade to cut away the plaque.
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
- A. I have no appetite.
- B. The pain hurts so much it is making me nauseous.
- C. When I position myself on my right side, it makes the pain worse.
- D. The pain seems to be gone now.
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis. Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.
Select the 5 findings that can cause delayed wound healing.
- A. History of diabetes mellitus.
- B. History of hyperlipidemia.
- C. Wound infection.
- D. Decreased pedal perfusion.
- E. Fasting blood glucose.
Correct Answer: A,B,C,D,E
Rationale: The correct answer includes all factors that can contribute to delayed wound healing. A: Diabetes mellitus impairs wound healing due to vascular and neuropathic complications. B: Hyperlipidemia can lead to poor circulation and impair the immune response. C: Wound infection prolongs the inflammatory phase and delays healing. D: Decreased pedal perfusion compromises blood flow necessary for tissue repair. E: Elevated fasting blood glucose levels hinder immune function and collagen synthesis. These factors collectively contribute to delayed wound healing. Other choices are incorrect as they do not directly impact wound healing in the same manner as the selected options.
A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 18/min.
- B. Blood pressure 102/66 mm Hg.
- C. Yellow-green drainage on the surgical incision.
- D. Straw-colored urine from an indwelling urinary catheter.
Correct Answer: C
Rationale: The correct answer is C because yellow-green drainage on the surgical incision can indicate an infection, which is a critical postoperative complication that requires immediate attention from the provider. This finding suggests the presence of pus or other infectious material in the wound, increasing the risk of further complications like wound dehiscence or systemic infection. Reporting this to the provider promptly allows for timely intervention such as wound exploration, debridement, and initiation of appropriate antibiotics.
The other choices are not as concerning in the immediate postoperative period:
A: Respiratory rate within normal range
B: Blood pressure within normal range
D: Straw-colored urine is expected from an indwelling urinary catheter, indicating adequate kidney function and hydration.