Nokea
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. The nurse is reviewing the client's electronic medical record (EMR). Which of the following statements in the EMR indicate the client's condition is improving since implementing interventions?
- A. Client reports pain as a 4 on a scale of 0 to 10.
- B. Bilateral breath sounds clear and present throughout.
- C. Right leg warm to touch, incision dressing dry and intact.
- D. Wound drain negative-pressure system, draining small amount of serosanguinous fluid.
Correct Answer: C
Rationale: Fasciotomy relieves compartment syndrome pressure, so improvement hinges on limb perfusion and wound stability. Right leg warm to touch with a dry, intact dressing indicates good circulation and no excessive bleeding or infection key recovery signs post-fasciotomy. Pain at 4/10 may suggest improvement if previously higher, but it's subjective and less specific without baseline comparison. Clear breath sounds are reassuring but unrelated to the surgical site unless pulmonary complications were a concern, not implied here. Small serosanguinous drainage is normal initially, but small' alone doesn't confirm progress without prior volume context. Warmth and a stable dressing directly reflect surgical success restored blood flow and wound healing making it the strongest EMR indicator of improvement, per postoperative assessment priorities.
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A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?
- A. Physical inactivity
- B. Family history of colorectal cancer
- C. High-fiber diet
- D. Age over 50 years
- E. History of diabetes mellitus
Correct Answer: B
Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Request a dosage increase if the apical heart rate is less than 60/min.
- B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- C. Administer the medication with an antacid.
- D. Instruct the client to expect increased hair growth.
Correct Answer: B
Rationale: Propranolol is a beta-blocker, and it should be withheld if the systolic blood pressure is below 90 mm Hg to prevent hypotension. A heart rate below 60/min might also warrant withholding, not increasing, the dose, and the other options are unrelated to its administration.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.