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A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in the lower legs, particularly around the medial malleolus due to poor circulation in chronic venous insufficiency. The pressure and pooling of blood in the veins can lead to tissue breakdown and ulcer formation in this area. Assessing the medial malleolus for the presence of a venous ulcer is crucial in managing the client's condition.
Incorrect Choices:
A: Tip of the toes - Venous ulcers are less likely to occur in this area as it is more distal and less affected by venous insufficiency.
C: Ball of the foot - Venous ulcers are more commonly found in the lower legs rather than the ball of the foot.
D: Heel of the foot - While ulcers can develop on the heel, they are less likely to be venous ulcers in chronic venous insufficiency compared to the medial malleol
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A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform strength-building arm exercises using a 15-pound weight.'
- B. I should expect less than 25 mL of secretions per day in the drainage devices.'
- C. I will have to wait 2 months before additional saline can be added to my breast expander.'
- D. I will keep my left arm flexed at the elbow as much as possible.'
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
- A. 100 mL of red drainage
- B. 75 mL of greenish-yellow drainage
- C. 200 mL of brown drainage
- D. 150 mL of serosanguineous drainage
Correct Answer: A
Rationale: The correct answer is A: 100 mL of red drainage. Red drainage from an NG tube may indicate active bleeding, which is a concerning finding post-abdominal surgery. This could suggest a potential internal bleeding or vascular injury. The nurse should report this finding to the provider immediately for further evaluation and intervention.
The other choices are incorrect because:
B: 75 mL of greenish-yellow drainage - This could be indicative of bile drainage, which is expected after abdominal surgery.
C: 200 mL of brown drainage - Brown drainage is likely due to old blood or bile, which can be normal in the immediate postoperative period.
D: 150 mL of serosanguineous drainage - Serosanguineous drainage is a mixture of blood and clear fluid, which can be expected after surgery.
Therefore, the correct answer is A due to the potential seriousness of active bleeding indicated by red drainage.
A nurse is caring for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowler’s position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. After a lumbar laminectomy, it is essential to prevent twisting or bending at the waist to avoid damaging the surgical site. Log rolling with a turning sheet maintains proper alignment of the spine. Encouraging independent ambulation (A) may put strain on the surgical area. Positioning in a high Fowler's position (C) may increase pressure on the surgical site. Applying a heating pad (D) can lead to increased inflammation and potential burns.
A nurse is caring for a client who has heart failure. Drag words from the choices below to fill
in each blank in the following sentence. The client is at risk for developing _________ and_________
Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (A) may not necessarily prevent wandering. Using chemical restraints (B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (D) may increase agitation and wandering behavior.