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In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
- A. Document the extent of the bruising in the medical record.
- B. Apply a cold compress to the area.
- C. Elevate the affected limb.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.
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The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?
- A. Cognitive.
- B. Affective.
- C. Comprehension.
- D. Psychomotor.
Correct Answer: B
Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife's ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.
The parents of a 6-year-old recently diagnosed with asthma should be taught that symptoms of an acute episode of asthma are due to which physiological response?
- A. Inflammation of the mucous membrane and bronchospasm
- B. Increased mucus production and airway obstruction
- C. Hyperinflation of the lungs and alveolar collapse
- D. Bronchoconstriction and airway inflammation
Correct Answer: D
Rationale: The correct answer is D: Bronchoconstriction and airway inflammation. During an acute asthma episode, bronchoconstriction and airway inflammation occur, leading to difficulty breathing. Choices A, B, and C are incorrect. Inflammation of the mucous membrane and bronchospasm (Choice A) are part of the pathophysiology of asthma but do not fully explain the symptoms during an acute episode. Increased mucus production and airway obstruction (Choice B) are also seen in asthma but are not the primary cause of acute symptoms. Hyperinflation of the lungs and alveolar collapse (Choice C) are not typical features of an acute asthma episode.
When assessing a client with left-sided heart failure, which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Monitor the client's urine output.
- C. Administer a loop diuretic as prescribed.
- D. Administer morphine as prescribed.
Correct Answer: A
Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.
The nurse is assessing a client with left-sided heart failure. Which laboratory value is most concerning?
- A. Serum creatinine of 1.5 mg/dL
- B. Serum sodium of 136 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Hemoglobin of 12 g/dL
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client with left-sided heart failure as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias, which can exacerbate heart failure. Serum creatinine of 1.5 mg/dL is slightly elevated but not as immediately concerning as hyperkalemia. Serum sodium of 136 mEq/L is within the normal range. Hemoglobin of 12 g/dL is also within the normal range and not directly related to the client's left-sided heart failure.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Positive urine ketones
Correct Answer: C
Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis in a client with DKA, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis, which is reflected by a low serum bicarbonate level. Correcting the low serum bicarbonate is crucial to normalize the metabolic acidosis and improve the client's condition. While elevated serum glucose (choice A) and urine ketones (choice D) are characteristic of DKA, addressing the metabolic acidosis takes precedence. Serum potassium (choice B) levels may also need monitoring and management, but correcting the acidosis is the priority to prevent complications like cardiovascular collapse.