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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Potassium level.
- B. Prealbumin level.
- C. History of diabetes mellitus.
- D. History of hyperlipidemia.
- E. Wound infection.
- F. Decreased pedal perfusion.
- G. Fasting blood glucose.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A, D) are not directly linked to wound healing delays. Potassium level (A) mainly affects cardiac and muscle function, and hyperlipidemia (D) primarily impacts cardiovascular health, not wound healing directly.
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A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
- A. The client develops a life-threatening situation.
- B. The client has to be repositioned in the bed.
- C. The client complains of pain.
- D. The client needs to have an x-ray of the femur performed.
Correct Answer: A
Rationale: The correct answer is A: The client develops a life-threatening situation. In this scenario, the nurse can remove the weights from the traction device to address the life-threatening situation promptly. Removing the weights in such a situation takes precedence over other concerns like repositioning, pain complaints, or even the need for an x-ray. Life-threatening situations must always be prioritized in patient care to ensure their safety and well-being. It is crucial for the nurse to act swiftly and appropriately in such emergencies to provide the necessary care and support to the client.
A nurse is caring for an 84-year-old male client in the medical unit. The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
- A. Teach the client about the condition.
- B. Encourage intake of low-sodium diet.
- C. Administer prescribed medications.
- D. Monitor vital signs regularly.
- E. Schedule a follow-up appointment with a specialist.
- F. Anemia
- G. Blood pressure
Correct Answer: A,C,D,E
Rationale: The correct answer is A,C,D,E. Firstly, the client is likely experiencing anemia based on the symptoms of fatigue, dizziness, and shortness of breath. Therefore, administering prescribed medications (C) to address the anemia is crucial. Teaching the client about the condition (A) helps improve understanding and compliance. Monitoring vital signs (D) is essential to track the client's response to treatment. Scheduling a follow-up appointment with a specialist (E) ensures ongoing evaluation and management. Encouraging intake of a low-sodium diet (B) is not directly related to anemia and may not be the priority in this case. Blood pressure (G) monitoring is important but not specific to anemia.
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
- A. Insert a nasogastric (NG) tube.
- B. Ask the client about the precipitating events.
- C. Obtain vital signs.
- D. Complete a head-to-toe assessment.
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)
- A. Increased appetite.
- B. Nausea.
- C. Increased energy level.
- D. Seeing halos around bright objects.
- E. Photophobia.
Correct Answer: B,D,E
Rationale: The correct manifestations correlating with a digoxin level of 2.3 ng/dL are Nausea, Seeing halos around bright objects, and Photophobia. Nausea is a common side effect of digoxin toxicity. Seeing halos around bright objects is a sign of visual disturbances associated with digoxin toxicity. Photophobia is sensitivity to light, which can occur with digoxin toxicity. Increased appetite and energy levels are not typically associated with digoxin toxicity and are therefore incorrect choices.
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
- A. Pancreatic pseudocyst.
- B. Electrolyte imbalance.
- C. Internal bleeding.
- D. Pleural effusion.
Correct Answer: C
Rationale: Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area. Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.