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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud’s phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these fi ndings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process.
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process.
- D. Risk for impaired skin integrity related to vasospastic process.
Correct Answer: B
Rationale: The client complains of numbness in her fingertips, thus Disturbed sensory perception (tactile) is the priority nursing diagnosis. The client does not complain of acute pain. The other data suggest that the circulation is adequate at this time, so neither Ineffective tissue perfusion nor Risk for impaired skin integrity is the priority nursing diagnosis.
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After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which of the following discharge instructions would be most effective for decreasing pain and edema?
- A. Take analgesics every 4 hours around the clock.
- B. Use a corticosteroid nasal spray as needed to control symptoms.
- C. Use a blood discernible humidity while sleeping.
- D. Apply cold compresses to the area.
Correct Answer: D
Rationale: Cold compresses reduce swelling and pain by constricting blood vessels. Analgesics should be taken as needed, not routinely. Corticosteroid sprays are for inflammation, not acute swelling. Humidifiers help with dryness but not directly with edema.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.
A client with a hip fracture is using a walker. Which observation indicates incorrect use of the walker?
- A. The client leans forward over the walker.
- B. The client advances the walker before stepping.
- C. The client uses the walker on both sides.
- D. The client keeps elbows slightly bent.
Correct Answer: A
Rationale: Leaning forward over the walker compromises balance and increases fall risk.
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.