Nokea
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.
- B. Large incisions will be made in the eschar to improve circulation.
- C. The procedure involves placing the client into a shower and removing the dead tissue.
- D. Dead tour will be non-surgically removed.
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.
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A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
- A. "I need something for the pain in my eye. I can't stand it."
- B. "It's hard to see with a patch on one eye. I'm afraid of falling"
- C. "My eye really itches, but I'm trying not to rub it."
- D. "The bright light in this room is really bothering me."
Correct Answer: A
Rationale: Severe pain after cataract surgery is unusual and could indicate complications like increased intraocular pressure or infection, requiring immediate reporting. Other comments reflect common post-surgical experiences.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
- A. Stop the infusion of blood,
- B. Inform the provider.
- C. Obtain a urine specimen.
- D. Notify the laboratory.
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
- A. 1 cup canned black beans
- B. 8 a whole milk
- C. 1.5 oz raisins
- D. 8 or black tea
Correct Answer: A
Rationale: Black beans are high in iron, making them an excellent dietary choice for iron deficiency anemia. Milk can inhibit iron absorption due to calcium, raisins have less iron than beans, and tea contains tannins that reduce iron absorption.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.