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A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?
- A. Granulation tissue forming at the bottom of the wound bed
- B. Healing of the wound is prolonged
- C. Skin edges of the wound are sutured closed
- D. Wound is contaminated at the time of injury
Correct Answer: C
Rationale: The correct answer is C: Skin edges of the wound are sutured closed. In primary intention healing, the wound edges are approximated and closed with sutures, promoting faster healing and minimal scarring. Granulation tissue (A) is seen in secondary intention healing. Healing is not prolonged (B) in primary intention healing. Wound contamination (D) is not a characteristic of primary intention healing.
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A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
A nurse is caring for a client whose partner has recently died. The client states, 'I am learning how to pay my own bills.' The nurse should identify that the client is experiencing which of the following tasks in Worden’s Four Tasks of Grieving?
- A. Experiencing the pain of grief
- B. Finding an enduring connection while embarking on a new life
- C. Accepting the reality of the loss
- D. Adjusting to an environment without the deceased
Correct Answer: D
Rationale: The correct answer is D: Adjusting to an environment without the deceased. This task involves adapting to life without the presence of the deceased partner, such as taking on new responsibilities like paying bills. It signifies a significant step in the grieving process, as the individual begins to establish a new routine and sense of normalcy without their loved one.
Choice A (Experiencing the pain of grief) is not the correct answer because this task refers to acknowledging and processing the emotional pain associated with the loss, which is a different aspect of grieving.
Choice B (Finding an enduring connection while embarking on a new life) is not the correct answer as it involves integrating the memory and influence of the deceased into the individual's ongoing life, which is different from adjusting to the practical aspects of life without them.
Choice C (Accepting the reality of the loss) is not the correct answer as it pertains to coming to terms with the fact that the loved one has passed away, which is an important
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?
- A. Diaphoresis
- B. Weight loss
- C. Hypotension
- D. Tachycardia
Correct Answer: D
Rationale: The correct answer is D: Tachycardia. In circulatory overload, the body is trying to compensate for the increased volume of fluid in the circulatory system by increasing the heart rate to maintain adequate circulation. Diaphoresis (A) is excessive sweating, not typically associated with circulatory overload. Weight loss (B) is not expected as circulatory overload is characterized by excess fluid retention. Hypotension (C) is unlikely as the body's response to fluid overload is to increase blood pressure. Tachycardia (D) is the correct choice as the heart rate increases to help pump the excess fluid throughout the body.
A nurse is receiving report on a group of clients. Using the ABCDE priority framework which of the following clients should the nurse see first?
- A. A client who has early dementia and awoke confused to their location this morning
- B. A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
- C. A client who has pneumonia and has developed wheezing
- D. A client who is postoperative and has a urine output of 50 mL for the past 3 h
Correct Answer: C
Rationale: The correct answer is C because the client with pneumonia developing wheezing is experiencing a potential airway obstruction, impacting their breathing (airway). In the ABCDE priority framework, airway comes first to ensure adequate oxygenation. Choice A may indicate confusion but does not pose an immediate threat to life. Choice B has a fever, but unless there are other concerning symptoms, it does not require immediate attention. Choice D has decreased urine output, indicating a potential issue with circulation or kidneys, but it is not immediately life-threatening. Therefore, C takes precedence due to the potential airway compromise.