Nokea
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
- A. Evisceration
- B. Hematoma
- C. Dehiscence
- D. Granulation
Correct Answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
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A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
- A. Massaging the reddened areas
- B. Performing range of motion exercises
- C. Administering antithrombotics as ordered
- D. Feeding the client a high-carbohydrate diet
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
- A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
- B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
- C. The client should lie flat on their back for a specific period following the procedure.
- D. The risks of the procedure include headache, back pain, and infection.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.
A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct Answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.