Nokea
A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire while attempting to light a charcoal grill. The client ripped off the shirt immediately, without unbuttoning the sleeves, which caused circumferential burns to both wrists. When the client is admitted, which intervention should the nurse implement first?
- A. Monitor pulse intensity.
- B. Evaluate extremity sensation.
- C. Assess range of motion.
- D. Place sterile bandage on both wrists.
Correct Answer: A
Rationale: Monitoring pulse intensity is the priority to ensure circulation is not compromised due to circumferential burns.
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In a patient with anemia, which of the following is the primary symptom to assess?
- A. Fever.
- B. Chest pain.
- C. Shortness of breath.
- D. Muscle cramps.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath. In a patient with anemia, the primary symptom to assess is shortness of breath. Anemia leads to a reduced oxygen-carrying capacity of the blood, resulting in tissues not receiving adequate oxygen. This can manifest as shortness of breath, especially during physical exertion. Fever (Choice A), chest pain (Choice B), and muscle cramps (Choice D) are not typically primary symptoms of anemia. Fever may suggest an infection, chest pain can be indicative of cardiac issues, and muscle cramps may be related to electrolyte imbalances or neuromuscular disorders.
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Inform the healthcare provider of the need for potassium replacement.
- B. Prepare to administer a glucose-insulin-potassium replacement.
- C. Change the plan of care to include hourly urinary output measurement.
- D. Instruct the client to increase daily intake of potassium-rich foods.
Correct Answer: A
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.
A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Competent venous valves.
- B. Decreased blood volume.
- C. Increase in muscular activity.
- D. Increased venous pressure.
Correct Answer: D
Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.
What is the primary purpose of administering anticoagulants to a patient with atrial fibrillation?
- A. To reduce blood pressure.
- B. To prevent clot formation.
- C. To prevent arrhythmias.
- D. To reduce inflammation.
Correct Answer: B
Rationale: The primary purpose of administering anticoagulants to a patient with atrial fibrillation is to prevent clot formation. Patients with atrial fibrillation are at an increased risk of forming blood clots in the heart, which can lead to stroke if they travel to the brain. Anticoagulants help to reduce this risk by inhibiting the clotting process. Therefore, choices A, C, and D are incorrect because anticoagulants do not primarily aim to reduce blood pressure, prevent arrhythmias, or reduce inflammation in patients with atrial fibrillation.