Nokea
Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse should explain it is from which source?
- A. A cadaver
- B. Another animal species
- C. The burned client themselves
- D. A man-made synthetic source
Correct Answer: B
Rationale: Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pig skin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client. Synthetic dressings are also available for covering burn wounds.
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A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway?
- A. Insert oropharyngeal airway.
- B. Tilt the head and lift the chin.
- C. Place in the recovery position.
- D. Stabilize the skull and push up the jaw.
Correct Answer: D
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.
The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.
A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply.
- A. Restrict the client's movements.
- B. Turn the supine client to the side.
- C. Open the unconscious client's airway.
- D. Gently guide the standing client to the floor.
- E. Place a padded tongue blade into the client's mouth.
- F. Loosen any restrictive clothing that the client is wearing.
Correct Answer: B,C,D,F
Rationale: Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.
Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome?
- A. Weight
- B. Albumin levels
- C. Activity tolerance
- D. Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.