Nokea
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
- A. Reinforce the wound dressing as needed with 4 × 4 gauze.
- B. Perform the ordered dressing change twice daily.
- C. Observe wound appearance and edges.
- D. Document wound characteristics.
Correct Answer: C
Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.
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To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: C
Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein
- B. The head and back are immobilized mechanically with a cervical collar and back support
- C. Traction with weights and pulleys is applied
- D. A turning frame is used EMERGENCY AND DISASTER NURSING SITUATION: A group of high school teenagers went camping to Sohoton this summer for one week. You are the nurse assigned to this camp. For the first three days, you were busy with several emergencies.
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
- A. It’s normal and requires no action
- B. It calls for a repeat Pap test in 6 weeks
- C. It calls for a repeat Pap test in 3 months
- D. It calls for a biopsy as soon as possible
Correct Answer: D
Rationale: The correct answer is D because a class V Pap test finding indicates severe abnormalities, such as high-grade dysplasia or carcinoma in situ. Therefore, the nurse should instruct the client to undergo a biopsy as soon as possible to confirm the diagnosis and initiate appropriate treatment promptly. Choices A, B, and C are incorrect because a class V result is not normal and requires immediate follow-up, rather than waiting or repeating the Pap test at a later time.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Rationale:
1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia.
2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling.
3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance.
4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage.
5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications.
Summary:
B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ.
C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation.
D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.