Nokea
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
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A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
The nurse is caring for a client prescribed digoxin. Which manifestations correlate with a digoxin level of 2.3 ng/dL (2.93 nmol/L)? Select all that apply.
- A. Nausea
- B. Drowsiness
- C. Photophobia
- D. Increased appetite
- E. Increased energy level
- F. Seeing halos around bright objects
Correct Answer: A,B,C,F
Rationale: Digoxin is a cardiac glycoside used to manage and treat heart failure, control ventricular rate in clients with atrial fibrillation, and treat and prevent recurrent paroxysmal atrial tachycardia. The therapeutic range is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). Signs of toxicity include gastrointestinal disturbances, including anorexia, nausea, and vomiting; neurological abnormalities such as fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares; facial pain; personality changes; and ocular disturbances such as photophobia, halos around bright lights, and yellow or green color perception.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
- A. Loud wheezing
- B. Wheezing on expiration
- C. Noticeably diminished breath sounds
- D. Increased displays of emotional apprehension
Correct Answer: C
Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced.
The nurse is assigned to care for a client experiencing hypertonic labor contractions. The nurse plans to conserve the client's energy and promote rest by performing which intervention?
- A. Keeping the TV or radio on to provide distraction
- B. Assisting the client with breathing and relaxation techniques
- C. Keeping the room brightly lit so the client can watch her monitor
- D. Avoiding uncomfortable procedures such as intravenous infusions or epidural anesthesia
Correct Answer: B
Rationale: Breathing and relaxation techniques aid the client in coping with the discomfort of labor and conserving energy. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs.
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
- A. Bleeding ulcer
- B. Myocardial infarction
- C. Deep vein thrombosis
- D. Streptococcal infection
Correct Answer: D
Rationale: The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.