Nokea
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
- A. Administering pain medication
- B. Encouraging fluids
- C. Turning the client every 1 to 2 hours
- D. Maintaining hygiene
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.
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An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply.
- A. The victim with chemical spills on both arms.
- B. The victim with third-degree burns of both legs.
- C. The victim with first-degree burns of both hands.
- D. The victim in respiratory distress.
- E. The victim who inhaled smoke.
Correct Answer: A,B,D,E
Rationale: Victims with chemical burns, third-degree burns, respiratory distress, or smoke inhalation require specialized care at a burn center due to the severity and potential complications of these injuries.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply.
- A. To ensure efficient and accurate communication.
- B. To prevent medication errors.
- C. To ensure client safety.
- D. To make it easier for clients to understand the medication orders.
- E. To make data entry into a computerized health record easier.
Correct Answer: A,B,C
Rationale: Eliminating dangerous abbreviations ensures clear communication, prevents medication errors, and enhances client safety by reducing misinterpretations. Client understanding and data entry ease are secondary benefits.
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action?
- A. Lower the head of the bed and call the physician.
- B. Prepare an aspiration tray.
- C. Mark the area with a skin pencil at the outer perippliess to the crackling.
- D. Turn off the suction of the chest drainage system.
Correct Answer: C
Rationale: The crackling sensation indicates subcutaneous emphysema. Marking the area monitors its spread, guiding further action. Lowering the bed, preparing aspiration, or turning off suction are not immediate priorities.
The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
- A. Listening to the client's feelings of concern.
- B. Completing the client's care in a nonhurried manner.
- C. Performing all of the client's care at one time.
- D. Instructing the client to dispose of tissue after blowing the nose.
Correct Answer: C
Rationale: Performing all care at one time minimizes disruptions and reduces the risk of introducing pathogens to a neutropenic client in isolation. Emotional support, nonhurried care, and tissue disposal are important but secondary to infection prevention.
The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?
- A. Whole grains.
- B. Green leafy vegetables.
- C. Meats and dairy products.
- D. Broccoli and brussels sprouts.
Correct Answer: C
Rationale: Vitamin B12 is primarily found in animal products, such as meats and dairy products, making them the best dietary sources. Whole grains, green leafy vegetables, broccoli, and brussels sprouts contain little to no vitamin B12. Clients with B12 deficiency, such as those with pernicious anemia, should be encouraged to consume meats and dairy to meet their B12 needs.