Nokea
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Wound infection.
- B. Obesity.
- C. Altered mental status.
- D. Pain medication administration.
- E. Poor nutritional state.
Correct Answer: A,B,E
Rationale: The correct factors for dehiscence risk are wound infection, obesity, and poor nutritional state. Wound infection can delay healing and weaken tissue integrity, leading to dehiscence. Obesity puts extra strain on the incision site, increasing the likelihood of separation. Poor nutritional state impairs the body's ability to heal properly. Altered mental status and pain medication administration do not directly impact tissue integrity or healing process, thus are not significant risk factors for dehiscence.
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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.
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
- A. I have no appetite.
- B. The pain hurts so much it is making me nauseous.
- C. When I position myself on my right side, it makes the pain worse.
- D. The pain seems to be gone now.
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis. Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
- A. Soon those shock waves will get rid of my gallstones.
- B. I’ll have a camera put down my throat so they can see my gallbladder.
- C. They are going to use dye to examine my gallbladder and ducts.
- D. They’ll put medication into my gallbladder to dissolve the stones.
Correct Answer: C
Rationale: The correct answer is C because the client's statement indicates an understanding of the procedure. Oral cholangiogram involves injecting dye to visualize the gallbladder and ducts. Choice A is incorrect as shock waves are used in lithotripsy, not oral cholangiogram. Choice B is incorrect as the procedure involves dye, not a camera down the throat. Choice D is incorrect as medication is not used in this procedure.
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 is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
- A. Fat neck veins.
- B. Hypotension.
- C. Poor skin turgor.
- D. Bradycardia.
- E. Pale yellow urine.
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration. Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.