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A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
Correct Answer: 72
Rationale: The Rule of Nines is a method used to estimate the total body surface area (TBSA) burned in a patient with severe burns. According to this rule, each major body part represents a specific percentage of the TBSA. In an adult, the head accounts for 9%, each upper extremity is 9% (18% total), the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18% (36% total), and the genital area is 1%. Therefore, if a client has sustained severe burn injuries in a grease fire, the nurse should estimate that the client has burned approximately 72% of their TBSA. This calculation is crucial in determining the severity of the burns and guiding appropriate treatment. The correct answer is 72 because it reflects the accurate estimation of the TBSA burned using the Rule of Nines. The other choices are incorrect as they do not align with the standard percentages
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A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
- A. Vitamin B supplements.
- B. Iron supplements.
- C. Vitamin B12 injections.
- D. Blood transfusions.
Correct Answer: C
Rationale: The correct answer is C: Vitamin B12 injections. Pernicious anemia is caused by a lack of intrinsic factor necessary for Vitamin B12 absorption. Vitamin B12 injections bypass the need for intrinsic factor, ensuring the client receives an adequate amount of the vitamin. Iron supplements (B) are not effective in treating pernicious anemia as it is not related to iron deficiency. Vitamin B supplements (A) may not be absorbed effectively due to the lack of intrinsic factor. Blood transfusions (D) may be used for severe cases of anemia, but they do not address the underlying Vitamin B12 deficiency in pernicious anemia.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
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.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
- C. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- D. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
Correct Answer: C
Rationale: Correct Answer: C - The catheter will be used to compress the plaque against the coronary blood vessel wall.
Rationale: During a PTCA procedure, a balloon-tipped catheter is used to compress the plaque against the vessel wall, widening the artery lumen and improving blood flow. This process does not involve cutting away the plaque or taking pressure measurements. Option A is incorrect as the catheter does not spring open but rather compresses the plaque. Option B is incorrect as the catheter is not used for pressure measurements. Option D is incorrect as there is no embedded blade to cut away the plaque.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.