Nokea
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.
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A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid handwashing after eating.
- B. Avoid foods prepared with tap water.
- C. Avoid eating meat.
- D. Avoid covering sores with bandages.
Correct Answer: B
Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (A) is actually recommended for preventing the spread of infections. Avoiding eating meat (C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (D) is unrelated to the prevention of viral hepatitis.
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
- A. Moist skin.
- B. Blood in the urine.
- C. Spider angiomas.
- D. Tarry stools.
Correct Answer: C
Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively. Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin. Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys. Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
- A. Friction rub.
- B. Intermittent claudication.
- C. Cardiac murmur.
- D. Dependent rubor.
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice A) is more indicative of pericarditis, intermittent claudication (choice B) is associated with peripheral arterial disease, and dependent rubor (choice D) is seen in chronic arterial insufficiency. Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.
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.