Nokea
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.
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A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).
- A. 1 tbsp honey
- B. 120 mL milk
- C. 5 hard candies
- D. 240 mL regular soda
- E. 120 mL unsweetened fruit juice
Correct Answer: A,B,C,D
Rationale: A, B, C, D provide quick sugar sources to correct hypoglycemia; unsweetened juice (E) lacks sufficient glucose.
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia is a primary concern in dysphagia due to aspiration risk, potentially leading to infection.
A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?
- A. BMI of 20
- B. Peripheral neuropathy
- C. Immobility
- D. Hypoperfusion
- E. Prealbumin level of 16 mg/dL
Correct Answer: B,C,D,E
Rationale: B: Neuropathy reduces sensation. C: Immobility causes prolonged pressure. D: Hypoperfusion impairs tissue oxygenation. E: Low prealbumin indicates poor nutrition.