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A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
- A. Class I
- B. Class II
- C. Class III
- D. Class IV
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.
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During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
- A. Palpate turgor of skin
- B. Observe the color of the skin
- C. Conduct a Trousseau’s sign test
- D. Save urine to measure 17-ketosteroids
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
A client is prescribed enalapril (Vasotec) for treatment of heart failure. Which adverse effect should the nurse assess for following the initial administration of this drug?
- A. Jaundice
- B. Ototoxicity
- C. Low blood pressure
- D. Blurred vision
Correct Answer: C
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. One of the potential adverse effects of ACE inhibitors, including enalapril, is hypotension or low blood pressure. This is especially a concern following the initial administration of the drug, as it can cause a significant drop in blood pressure. Nurses should assess the patient for signs and symptoms of hypotension, such as dizziness, light-headedness, weakness, or fainting, after starting enalapril therapy. Monitoring blood pressure regularly and educating the patient about the possibility of low blood pressure is important to ensure patient safety and optimal outcomes.
The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion?
- A. Body mass index (BMI) 35.8
- B. Former cigarette smoker
- C. Blood pressure 132/88 mmHg
- D. Age 45 years
Correct Answer: B
Rationale: A former cigarette smoker is at increased risk for thrombus formation due to the damage smoking causes to the blood vessels, increasing the likelihood of blood clots. Smoking can also contribute to inflammation and increased platelet activation, further promoting clot formation. This risk factor is particularly concerning in a client undergoing a total hip replacement surgery, as immobility and surgery itself can also increase the risk of blood clots forming. Monitoring and addressing this risk factor is important in preventing potential complications such as deep vein thrombosis or pulmonary embolism in this client population. While the other assessment findings are important to consider for overall health, the former cigarette smoking status is specifically associated with thrombus formation in this scenario.
The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the
- A. client's room.
- B. pediatric ward waiting area.
- C. hospital cafeteria.
- D. pediatric ward play area.
Correct Answer: A
Rationale: For a 7-year-old client recovering from partial-thickness burns with sensitivity to loud noises and bright lights, along with a tendency to become overstimulated, the best teaching environment would be the client's room. This setting provides a familiar and comforting space where the client feels secure and less exposed to external stimuli that may trigger discomfort or anxiety. Being in her own room allows the client to focus better, feel more at ease, and have better communication with the nurse without distractions from bright lights, loud noises, or other people around. This controlled and peaceful environment contributes to a more effective teaching and learning experience for the client, promoting better understanding and retention of information.
What is the most accurate tool for assessing and diagnosing venous thrombosis?
- A. Ascending contrast venography
- B. Duplex venous ultrasonography
- C. Magnetic resonance imaging
- D. Plethysmography
Correct Answer: B
Rationale: Duplex venous ultrasonography is the most accurate tool for assessing and diagnosing venous thrombosis. It is a non-invasive imaging technique that combines Doppler flow studies with conventional ultrasonography. This allows for the visualization of blood flow in the veins and identification of any blood clots or obstructions. Duplex venous ultrasonography is highly sensitive and specific for detecting deep vein thrombosis (DVT) in the lower extremities, making it the preferred imaging modality for diagnosing venous thrombosis. Other imaging modalities like ascending contrast venography, magnetic resonance imaging, and plethysmography are less commonly used due to their disadvantages compared to duplex venous ultrasonography such as invasiveness, cost, and lower accuracy.