Nokea
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
- A. Elder abuse.
- B. Self-inflicted injury.
- C. Increased capillary fragility and permeability.
- D. Increased blood supply to the skin.
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.
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Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The nurse is assisting a client with crutches to ascend stairs. Which instruction is correct?
- A. Step up with the affected leg first.
- B. Use the handrail on the unaffected side.
- C. Advance both crutches to the next step first.
- D. Lean backward while stepping up.
Correct Answer: B
Rationale: Using the handrail on the unaffected side provides stability and safety while ascending stairs.
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?
- A. Butterfly dressing.
- B. Montgomery strap.
- C. Fine-mesh gauze dressing.
- D. Petroleum gauze dressing.
Correct Answer: D
Rationale: Petroleum gauze creates an airtight seal over the chest tube site, preventing air entry into the pleural space. Other dressings are less occlusive.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
- A. Temperature 105° F (40.5° C)
- B. Confusion
- C. Perspiration
- D. Tachycardia
- E. Signs of dehydration
- F. Hypotension
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.