Nokea
In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?
- A. Atherosclerotic plaque formation.
- B. Stasis of blood flow.
- C. Endothelial damage.
- D. Atherosclerotic vessel changes.
Correct Answer: B
Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.
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On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?
- A. Administer a sedative.
- B. Determine the client's blood pressure.
- C. Apply soft restraints.
- D. Call for assistance.
Correct Answer: B
Rationale: The correct intervention the nurse should implement first is to determine the client's blood pressure. Assessing the blood pressure is crucial in this situation to rule out physiological causes like hypotension leading to the client's disorientation. Administering a sedative (Choice A) without understanding the underlying cause may worsen the situation. Applying soft restraints (Choice C) should not be the initial action and can be considered later if necessary. Calling for assistance (Choice D) may be needed eventually, but assessing the client's blood pressure takes precedence to address the immediate concern.
A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct Answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.
A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?
- A. Review the last administration of IV pain medication.
- B. Administer a PRN dose of acetaminophen.
- C. Decrease IV fluids to keep the vein open (KVO) rate.
- D. Calculate total intake and output.
Correct Answer: C
Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.
What most influences the severity of respiratory distress syndrome (RDS)?
- A. Poor cough and gag reflex
- B. The gestational age at birth
- C. Administering high concentrations of oxygen
- D. The sex of the infant
Correct Answer: B
Rationale: The correct answer is B. The gestational age at birth most influences the severity of respiratory distress syndrome (RDS). RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low-birth weight infants. Therefore, the gestational age at birth is a key factor in determining the likelihood and severity of RDS. Choices A, C, and D are incorrect as they do not directly relate to the primary factor influencing the severity of RDS.
In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?
- A. Yellow.
- B. Black.
- C. Red.
- D. Green.
Correct Answer: A
Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.