Nokea
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Serous
- B. Sanguineous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection. Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
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A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Increased potassium level
- C. Decreased white blood cell count
- D. Increased serum albumin level
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat droplets enter the bloodstream and can affect various organs. One of the common complications is hypocalcemia due to the binding of calcium to the fatty acids, leading to decreased serum calcium levels. This can result in symptoms such as confusion, tetany, and seizures. The other choices are incorrect because: B: Increased potassium level is not typically associated with FES. C: Decreased white blood cell count is not a common finding in FES. D: Increased serum albumin level is not related to FES.
A home health nurse assesses an older adult with vision loss due to glaucoma. What is a safety hazard?
- A. Bright overhead lighting
- B. Presence of scatter rugs in the kitchen
- C. Using contrasting colors in home decor
- D. Wearing slip-resistant shoes
Correct Answer: B
Rationale: The correct answer is B: Presence of scatter rugs in the kitchen. Scatter rugs pose a tripping hazard for individuals with vision loss, especially in areas like the kitchen where spills and slippery surfaces are common. The other choices are incorrect because: A - Bright overhead lighting can actually be beneficial for those with vision loss by improving visibility; C - Using contrasting colors can aid in distinguishing objects and pathways; D - Wearing slip-resistant shoes can help prevent falls.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider?
- A. Headache
- B. Nausea
- C. Musculoskeletal pain
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can cause musculoskeletal pain as a common adverse effect. This is important to report because severe pain may indicate a more serious condition like osteoporosis or fractures. Headache, nausea, and fatigue are common side effects of anastrozole but usually not considered serious enough to report immediately. Summarily, while all options can occur with anastrozole, musculoskeletal pain warrants prompt reporting due to potential implications on bone health.