Nokea
An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.
Correct Answer: 37%
Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.
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The nurse monitoring a postoperative client should recognize which behaviors as indicators that the client is in pain? Select all that apply.
- A. Gasping
- B. Lip biting
- C. Muscle tension
- D. Pacing activities
- E. Staring out the window
- F. Asking for the television to be turned off
Correct Answer: A,B,C,D
Rationale: The nurse should assess verbalization, vocal response, facial and body movements, and social interaction as indicators of pain. Behavioral indicators of pain include gasping, lip biting (facial expressions), muscle tension, pacing activities, moaning, crying, grunting (vocalizations), grimacing, clenching teeth, wrinkling the forehead, tightly closing or widely opening the eyes or mouth, restlessness, immobilization, increased hand and finger movements, rhythmic or rubbing motions, protective movements of body parts (body movement), avoidance of conversation, focusing only on activities for pain relief, avoiding social contacts and interactions, and reduced attention span. Options 5 and 6 are not to be assumed as pain-related behaviors because there can be a variety of reasons for such actions.
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?
- A. Document the findings.
- B. Prepare for immediate birth.
- C. Increase the rate of an oxytocin infusion.
- D. Administer oxygen to the client via face mask.
Correct Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Although the finding needs to be documented, documentation is not the priority action in this situation. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency.
The nurse monitors a client prescribed a thiazide diuretic for which clinical manifestations of hypokalemia? Select all that apply.
- A. Muscle twitches
- B. Deep tendon hyporeflexia
- C. Prominent U wave on ECG
- D. General skeletal muscle weakness
- E. Hypoactive to absent bowel sounds
- F. Tall T waves on electrocardiogram (ECG)
Correct Answer: B,C,D,E
Rationale: Hypokalemia is a serum potassium level less than 3.5 mEq/L. Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.
A client hospitalized with a diagnosis of thrombophlebitis is being treated with heparin infusion therapy. About 24 hours after the infusion has begun, the nurse notes that the client's partial thromboplastin time (PTT) is 65 seconds with a control of 30 seconds. What nursing action should the nurse implement?
- A. Discontinue the heparin infusion.
- B. Prepare to administer protamine sulfate.
- C. Notify the primary health care provider of the laboratory results.
- D. Include in report that the client is adequately anticoagulated.
Correct Answer: D
Rationale: The effectiveness of heparin therapy is monitored by the results of the PTT. Desired range for therapeutic anticoagulation is 1.5 to 2.5 times the control. A PTT of 65 seconds is within the therapeutic range. Therefore, options 1, 2, and 3 are incorrect actions.
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply.
- A. Hypertension
- B. Flat neck veins
- C. Increased cyanosis
- D. Tracheal deviation to the right
- E. Diminished breath sounds on the left
- F. Observable asymmetry of the thorax
Correct Answer: C,D,E,F
Rationale: A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise.