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A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
- A. Hypervolemia.
- B. Hyperkalemia.
- C. Low hemoglobin.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (A) is less likely due to fluid shifts, low hemoglobin (C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (D) is not a common laboratory finding in this scenario.
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A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A nurse is caring for an 84-year-old male client in the medical unit. The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
- A. Teach the client about the condition.
- B. Encourage intake of low-sodium diet.
- C. Administer prescribed medications.
- D. Monitor vital signs regularly.
- E. Schedule a follow-up appointment with a specialist.
- F. Anemia
- G. Blood pressure
Correct Answer: A,C,D,E
Rationale: The correct answer is A,C,D,E. Firstly, the client is likely experiencing anemia based on the symptoms of fatigue, dizziness, and shortness of breath. Therefore, administering prescribed medications (C) to address the anemia is crucial. Teaching the client about the condition (A) helps improve understanding and compliance. Monitoring vital signs (D) is essential to track the client's response to treatment. Scheduling a follow-up appointment with a specialist (E) ensures ongoing evaluation and management. Encouraging intake of a low-sodium diet (B) is not directly related to anemia and may not be the priority in this case. Blood pressure (G) monitoring is important but not specific to anemia.
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Fever usually accompanies myocardial infarction.
- B. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
- C. Headache is a common side effect of nitrates.
- D. Acetaminophen potentiates the therapeutic effect of nitrates.
- E. Acetaminophen potentiates the therapeutic effect of nitrates.
Correct Answer: C
Rationale: The correct answer is C. Headache is a common side effect of nitrates. Nitroglycerin, a common topical nitrate, is often prescribed for angina to dilate blood vessels and improve blood flow to the heart. One common side effect of nitrates is headache due to vasodilation, and acetaminophen is often prescribed to help alleviate this headache. Choices A and B are incorrect as they do not directly relate to why acetaminophen is prescribed with nitrates. Choice D is incorrect because acetaminophen does not potentiate the therapeutic effect of nitrates, it only helps with headache relief. Choice E is a duplicate of D.
Select the 5 findings that can cause delayed wound healing.
- A. History of diabetes mellitus.
- B. History of hyperlipidemia.
- C. Wound infection.
- D. Decreased pedal perfusion.
- E. Fasting blood glucose.
Correct Answer: A,B,C,D,E
Rationale: The correct answer includes all factors that can contribute to delayed wound healing. A: Diabetes mellitus impairs wound healing due to vascular and neuropathic complications. B: Hyperlipidemia can lead to poor circulation and impair the immune response. C: Wound infection prolongs the inflammatory phase and delays healing. D: Decreased pedal perfusion compromises blood flow necessary for tissue repair. E: Elevated fasting blood glucose levels hinder immune function and collagen synthesis. These factors collectively contribute to delayed wound healing. Other choices are incorrect as they do not directly impact wound healing in the same manner as the selected options.