Nokea
A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 18/min.
- B. Blood pressure 102/66 mm Hg.
- C. Yellow-green drainage on the surgical incision.
- D. Straw-colored urine from an indwelling urinary catheter.
Correct Answer: C
Rationale: The correct answer is C because yellow-green drainage on the surgical incision can indicate an infection, which is a critical postoperative complication that requires immediate attention from the provider. This finding suggests the presence of pus or other infectious material in the wound, increasing the risk of further complications like wound dehiscence or systemic infection. Reporting this to the provider promptly allows for timely intervention such as wound exploration, debridement, and initiation of appropriate antibiotics.
The other choices are not as concerning in the immediate postoperative period:
A: Respiratory rate within normal range
B: Blood pressure within normal range
D: Straw-colored urine is expected from an indwelling urinary catheter, indicating adequate kidney function and hydration.
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A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?
- A. 9 percent.
- B. 18 percent.
- C. 36 percent.
- D. 54 percent.
Correct Answer: B
Rationale: The correct answer is B (18 percent). The rule of nines is used to estimate the percentage of total body surface area (TBSA) affected by burns. According to this rule, each arm represents 9% of the TBSA (9% front + 9% back = 18%). Therefore, burns on both front and back of both arms would total 18% TBSA. Choices A, C, and D are incorrect because they do not accurately reflect the TBSA affected by burns on both arms. Choice A (9 percent) represents the TBSA of one arm, not both. Choices C (36 percent) and D (54 percent) overestimate the TBSA since they do not consider the rule of nines for the arms.
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses.
- B. Complaints of leg discomfort.
- C. Toes are warm and demonstrate a brisk capillary refill.
- D. Drainage at the pin sites.
Correct Answer: A
Rationale: The correct answer is A: Weak pedal pulses. Buck's traction is used for immobilization and alignment of fractures, particularly femoral fractures. Weak pedal pulses indicate impaired circulation, which could lead to complications like compartment syndrome or deep vein thrombosis. Monitoring pulses is crucial in assessing the circulation to the affected limb. Choice B (Complaints of leg discomfort) is common and expected with traction but doesn't indicate a complication. Choice C (Toes are warm and demonstrate a brisk capillary refill) indicates good circulation. Choice D (Drainage at the pin sites) may indicate infection but is not a specific complication related to traction.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Wound infection.
- B. Obesity.
- C. Altered mental status.
- D. Pain medication administration.
- E. Poor nutritional state.
Correct Answer: A,B,E
Rationale: The correct factors for dehiscence risk are wound infection, obesity, and poor nutritional state. Wound infection can delay healing and weaken tissue integrity, leading to dehiscence. Obesity puts extra strain on the incision site, increasing the likelihood of separation. Poor nutritional state impairs the body's ability to heal properly. Altered mental status and pain medication administration do not directly impact tissue integrity or healing process, thus are not significant risk factors for dehiscence.
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- A. The area surrounding the insertion site feels warm to the touch.
- B. The infusion rate has stopped but the tubing is not kinked.
- C. There is fluid leaking around the insertion site.
- D. There is no blood return when the tubing is aspirated.
Correct Answer: A
Rationale: The correct answer is A because warmth at the insertion site is a classic sign of phlebitis, indicating inflammation of the vein. This is due to irritation from the IV catheter. Choice B is incorrect because the infusion rate stopping is not specific to phlebitis. Choice C is incorrect as fluid leaking suggests an issue with the dressing or the catheter. Choice D is incorrect as no blood return could indicate a clot but not necessarily phlebitis.
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
- A. Remove the vest daily to inspect the client’s skin integrity.
- B. Check that the halo jacket is snug against the client’s skin.
- C. Provide range of motion to the client’s neck.
- D. Monitor the client for an elevated temperature.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (Choice A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (Choice B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (Choice C) is contraindicated with a halo device as it can cause serious injury.