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A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
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A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
- A. Diaphoresis
- B. Retractions
- C. Cyanosis
- D. Restlessness
Correct Answer: D
Rationale: Restlessness is an early sign of inadequate oxygenation, indicating the body's attempt to compensate for low oxygen levels.
A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)
- A. Cleanse the mask or collar with soapy water every other day.
- B. Make sure the straps on the mask are secure but not too tight.
- C. Check the tops of his ears regularly for skin breakdown.
- D. Post 'no smoking' warning signs at home in a prominent location.
- E. Apply petroleum jelly around and inside the nares.
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making sure the straps on the mask are secure but not too tight is essential to ensure proper oxygen delivery without discomfort or skin irritation.
C: Checking the tops of the ears regularly for skin breakdown is important as the oxygen tubing can cause pressure and skin breakdown in this area.
D: Posting 'no smoking' warning signs at home in a prominent location is crucial as oxygen is highly flammable and can lead to a fire hazard if exposed to smoking or open flames.
Summary:
A: Cleansing the mask or collar with soapy water every other day is not necessary for home oxygen therapy as frequent cleaning can damage the equipment.
E: Applying petroleum jelly around and inside the nares is not recommended as it can interfere with oxygen delivery and cause respiratory issues.
A nurse is caring for a client who has not voided for 8 hr following surgery. Which of the following actions should the nurse take first?
- A. Offer the client fluids.
- B. Perform a bladder scan.
- C. Insert an indwelling urinary catheter.
- D. Provide assistance to bathroom.
Correct Answer: B
Rationale: The correct answer is B: Perform a bladder scan. This is the first action the nurse should take because it provides valuable information about the client's bladder status without invasive intervention. The bladder scan will help determine if the client has urinary retention, which could be the reason for not voiding after surgery. Offering fluids (choice A) is important but should come after assessing the bladder. Inserting a urinary catheter (choice C) is invasive and should only be done if necessary. Providing assistance to the bathroom (choice D) is not appropriate if there is a possibility of urinary retention.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.