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A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
- A. Airway obstruction.
- B. Pneumonia.
- C. Pneumothorax.
- D. Fat embolism.
Correct Answer: D
Rationale: The correct answer is D: Fat embolism. Fat embolism can occur in clients with long bone fractures, like a femoral head fracture. Fat emboli can travel to the lungs leading to respiratory distress, shortness of breath, and dyspnea. This is a potential complication that can occur within the first 24-48 hours post-injury. Fat embolism is characterized by respiratory symptoms and can lead to hypoxia and respiratory failure.
Other choices are incorrect because:
A: Airway obstruction typically presents with choking or difficulty swallowing, not specifically with shortness of breath and dyspnea.
B: Pneumonia would typically present with fever, productive cough, and chest pain, not sudden-onset shortness of breath.
C: Pneumothorax presents with sudden chest pain and shortness of breath due to air in the pleural space, not directly related to a femoral head fracture.
Overall, the key to this question is
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A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
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.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.