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Select the 5 findings that can cause delayed wound healing.
- A. History of diabetes mellitus.
- B. History of hyperlipidemia.
- C. Wound infection.
- D. Decreased pedal perfusion.
- E. Fasting blood glucose.
Correct Answer: A,B,C,D,E
Rationale: The correct answer includes all factors that can contribute to delayed wound healing. A: Diabetes mellitus impairs wound healing due to vascular and neuropathic complications. B: Hyperlipidemia can lead to poor circulation and impair the immune response. C: Wound infection prolongs the inflammatory phase and delays healing. D: Decreased pedal perfusion compromises blood flow necessary for tissue repair. E: Elevated fasting blood glucose levels hinder immune function and collagen synthesis. These factors collectively contribute to delayed wound healing. Other choices are incorrect as they do not directly impact wound healing in the same manner as the selected options.
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A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
- A. Moist skin.
- B. Blood in the urine.
- C. Spider angiomas.
- D. Tarry stools.
Correct Answer: C
Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively. Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin. Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys. Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.
A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Potassium level.
- B. Prealbumin level.
- C. History of diabetes mellitus.
- D. History of hyperlipidemia.
- E. Wound infection.
- F. Decreased pedal perfusion.
- G. Fasting blood glucose.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A, D) are not directly linked to wound healing delays. Potassium level (A) mainly affects cardiac and muscle function, and hyperlipidemia (D) primarily impacts cardiovascular health, not wound healing directly.
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Fever usually accompanies myocardial infarction.
- B. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
- C. Headache is a common side effect of nitrates.
- D. Acetaminophen potentiates the therapeutic effect of nitrates.
- E. Acetaminophen potentiates the therapeutic effect of nitrates.
Correct Answer: C
Rationale: The correct answer is C. Headache is a common side effect of nitrates. Nitroglycerin, a common topical nitrate, is often prescribed for angina to dilate blood vessels and improve blood flow to the heart. One common side effect of nitrates is headache due to vasodilation, and acetaminophen is often prescribed to help alleviate this headache. Choices A and B are incorrect as they do not directly relate to why acetaminophen is prescribed with nitrates. Choice D is incorrect because acetaminophen does not potentiate the therapeutic effect of nitrates, it only helps with headache relief. Choice E is a duplicate of D.
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
- A. Airway obstruction.
- B. Pneumonia.
- C. Pneumothorax.
- D. Fat embolism.
Correct Answer: D
Rationale: The correct answer is D: Fat embolism. Fat embolism can occur in clients with long bone fractures, like a femoral head fracture. Fat emboli can travel to the lungs leading to respiratory distress, shortness of breath, and dyspnea. This is a potential complication that can occur within the first 24-48 hours post-injury. Fat embolism is characterized by respiratory symptoms and can lead to hypoxia and respiratory failure.
Other choices are incorrect because:
A: Airway obstruction typically presents with choking or difficulty swallowing, not specifically with shortness of breath and dyspnea.
B: Pneumonia would typically present with fever, productive cough, and chest pain, not sudden-onset shortness of breath.
C: Pneumothorax presents with sudden chest pain and shortness of breath due to air in the pleural space, not directly related to a femoral head fracture.
Overall, the key to this question is
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
- A. Fat neck veins.
- B. Hypotension.
- C. Poor skin turgor.
- D. Bradycardia.
- E. Pale yellow urine.
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration. Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.