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A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
- A. Review the results of culture and sensitivity testing of the wound.
- B. Look for the presence of a pressure dressing over the wound.
- C. Determine if the client has increased pain from exposed nerve endings.
- D. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.
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The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.
The nurse is assisting a client with crutches to ascend stairs. Which instruction is correct?
- A. Step up with the affected leg first.
- B. Use the handrail on the unaffected side.
- C. Advance both crutches to the next step first.
- D. Lean backward while stepping up.
Correct Answer: B
Rationale: Using the handrail on the unaffected side provides stability and safety while ascending stairs.
After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching?
- A. I will take my vitamins while I'm on this drug.'
- B. I must not drink any alcohol while I'm taking this drug.'
- C. I should brush my teeth after every meal.'
- D. I will continue taking my birth control pills.'
Correct Answer: A
Rationale: Methotrexate can interact with certain vitamins (e.g., folic acid) if not prescribed, requiring medical guidance. The other statements align with safe methotrexate use.
The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate 57 bpm
- B. SpO2 of 94% on room air
- C. Blood pressure in 1 mm/s
- D. Ankle brachial index of 0.65
Correct Answer: D
Rationale: An ankle-brachial index (ABI) of 0.65 is significantly below the normal range (0.9–1.3), indicating potential peripheral vascular disease (PVD) due to arterial insufficiency. This finding warrants further evaluation, especially given the client's symptoms of claudication (pain during exercise relieved by rest) and smoking history, which are risk factors for PVD. The other options€”heart rate, SpO2, and blood pressure€”are either normal or irrelevant in this context.
A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on:
- A. The amount of ulceration of the lesion.
- B. The age of the client.
- C. The location of the lesion on the body.
- D. The thickness of the lesion.
Correct Answer: D
Rationale: Melanoma prognosis primarily depends on lesion thickness (Breslow depth), as thicker lesions indicate deeper invasion and worse outcomes.