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 reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding should the nurse expect to note as a result of this condition?
- A. Dehydration
- B. Overhydration
- C. A high hematocrit level
- D. A low hemoglobin level
Correct Answer: D
Rationale: Pathological anemia of pregnancy is primarily caused by iron deficiency. When the hemoglobin level is below 11 mg/dL (110 mmol/L), iron deficiency is suspected. An indirect index of the oxygen-carrying capacity is determined via a packed red blood cell volume or hematocrit level. Dehydration and overhydration are not specifically associated with iron deficiency anemia.
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 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.
The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line. Which is a priority intervention to assure the client's safety?
- A. Assessing the client's pain level
- B. Assessing the client's temperature
- C. Preparing the client for a chest x-ray
- D. Monitoring the client's blood pressure (BP)
Correct Answer: C
Rationale: A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and verify catheter tip placement before initiating IV therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Pain management is important but is not the priority at this point. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.