Nokea
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
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A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
- A. Melanoma
- B. Squamous cell carcinoma
- C. Basal cell carcinoma
- D. Kaposi's sarcoma
Correct Answer: C
Rationale: The correct answer is C: Basal cell carcinoma. Basal cell carcinoma typically presents as a raised, flesh-colored lesion with pearly white borders. This type of skin cancer is the most common and is usually slow-growing with low metastatic potential. It is often found on sun-exposed areas such as the face, neck, and chest. Melanoma (A) is characterized by asymmetry, irregular borders, varied color, and a diameter larger than 6mm. Squamous cell carcinoma (B) is usually a firm, red nodule or a flat lesion with a scaly crust. Kaposi's sarcoma (D) typically presents as purple or blue-black patches or nodules on the skin.
A nurse is assessing a client who has fluid overload. Which of the following findings shouldn't the nurse expect?
- A. Increased heart rate
- B. Increased blood pressure
- C. Increased respiratory rate
- D. Increased hematocrit
Correct Answer: D
Rationale: The correct answer is D: Increased hematocrit. In fluid overload, there is an excess of fluid in the body, leading to dilution of blood components including hematocrit. Therefore, an increased hematocrit would not be expected. Increased heart rate (A), blood pressure (B), and respiratory rate (C) are all common findings in fluid overload due to the body's compensatory mechanisms to maintain adequate perfusion. Thus, these findings are expected.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
- A. Changing the client's linens
- B. Administering oral medications
- C. Taking vital signs
- D. Completing a dressing change
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective