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Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: The correct answer is D: 24 hours. Compartment syndrome occurs when pressure within a closed muscle compartment increases, leading to decreased circulation and potential tissue damage. Monitoring is crucial as irreversible damage can occur if left untreated. The 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure) are key indicators. Waiting for 48 hours (choice A) or 12 hours (choice C) is too long and can result in severe consequences. 2 hours (choice B) is too short a timeframe to assess for irreversible damage development, making 24 hours (choice D) the most appropriate timeframe for monitoring and intervention.
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A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
- A. Subjective data
- B. Objective data
- C. Secondary data
- D. Primary data
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.
Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
- A. Laryngeal cancer is one of the most preventable types of cancer
- B. Inhaling polluted air isn’t a risk factor for laryngeal cancer
- C. Laryngeal cancer occurs primarily in women
- D. Adenocarcinoma accounts for most cases of laryngeal cancer
Correct Answer: A
Rationale: The correct answer is A: Laryngeal cancer is one of the most preventable types of cancer. This is because the primary risk factors for laryngeal cancer are largely related to lifestyle choices such as smoking, excessive alcohol consumption, and exposure to certain occupational hazards. By avoiding these risk factors, individuals can significantly reduce their chances of developing laryngeal cancer.
Choices B, C, and D are incorrect:
B: Inhaling polluted air isn’t a risk factor for laryngeal cancer - This is incorrect as exposure to polluted air can contribute to the development of laryngeal cancer.
C: Laryngeal cancer occurs primarily in women - This is incorrect as laryngeal cancer occurs more frequently in men than in women.
D: Adenocarcinoma accounts for most cases of laryngeal cancer - This is incorrect as squamous cell carcinoma is the most common type of laryngeal cancer, not adenocarcin
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician’s orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia.
Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness.
Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects.
Summary:
A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate.
B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders.
C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- A. Platelet count, prothrombin time, and partial thromboplastin time
- B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- C. Thrombin time, calcium levels, and potassium levels
- D. Fibrinogen level, WBC, and platelet count
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC.
Explanation for why other choices are incorrect:
- Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring.
- Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC.
- Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.