Nokea
An adult client who received partial thickness burns on 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the client's burn recovery?
- A. 5% dextrose in water
- B. 5% dextrose in 0.25 normal saline
- C. Total parenteral nutrition
- D. Lactated Ringer's
Correct Answer: D
Rationale: During the burn recovery phase, the nurse should prepare to administer Lactated Ringer's solution. Lactated Ringer's is the preferred fluid choice for burn patients as it helps replace lost fluids and electrolytes, maintain perfusion, and support organ function. Option A, 5% dextrose in water, is not the appropriate choice for fluid resuscitation in burn patients. Option B, 5% dextrose in 0.25 normal saline, does not provide the necessary electrolytes needed for burn recovery. Option C, Total parenteral nutrition, may be considered later in the treatment but is not the initial fluid of choice for burn recovery.
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The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow.
- B. Increased blood flow.
- C. Slow blood flow.
- D. Thrombus formation.
Correct Answer: A
Rationale: The correct answer is A: 'Decreased blood flow.' In peripheral vascular disease (PVD), there is a narrowing or blockage of blood vessels, leading to reduced blood flow to the extremities. This decreased blood flow results in inadequate oxygen supply to the muscles, causing pain, especially during physical activity when oxygen demand increases. Choice B, 'Increased blood flow,' is incorrect because PVD is characterized by impaired blood circulation rather than increased flow. Choice C, 'Slow blood flow,' is not precise as PVD involves a more significant reduction in blood flow. Choice D, 'Thrombus formation,' is related to the formation of blood clots within vessels, which can be a complication of PVD but is not its main characteristic.
The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?
- A. Eats a vegetarian diet with cheese 2 to 3 times a day
- B. Experiences additional stress since adopting a child
- C. Jogs more frequently than usual daily routine
- D. Drinks several bottles of carbonated water daily
Correct Answer: D
Rationale: The correct answer is D. Drinking several bottles of carbonated water daily may contribute to renal calculi formation due to the high mineral content. Carbonated drinks can increase the risk of kidney stones due to their high levels of phosphoric acid and caffeine, which can lead to the formation of crystals in the urine. Choices A, B, and C are less likely to directly contribute to an increased risk of renal calculi compared to the excessive consumption of carbonated water.
An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin.
- B. Follow a reduced-calorie, reduced-fat diet.
- C. Inspect the involved areas daily for new ulcerations.
- D. Instruct the client to limit activities of daily living (ADLs).
Correct Answer: A
Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.
The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy.
- B. Contraction.
- C. Gangrene.
- D. Rubor.
Correct Answer: C
Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.
The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct Answer: B
Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.