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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When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.
A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial?
- A. Obtain baseline arterial blood gases.
- B. Obtain baseline pulse oximetry levels.
- C. Apply the mask to the face with a snug fit.
- D. Remove the mask for deep breathing exercises.
Correct Answer: C
Rationale: The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
- A. Identifies that the tube is draining normally
- B. Assesses the tube to locate a possible occlusion
- C. Auscultates the lungs for appropriate bilateral expansion
- D. Assists the client with frequent coughing and deep breathing
Correct Answer: B
Rationale: After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.
The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?
- A. Red
- B. Pink
- C. White
- D. Yellow
Correct Answer: A
Rationale: The uterus rids itself of the debris that remains after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow or contain large clots; if it does, the cause should be investigated without delay.
The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.