Nokea
The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
- A. The need to remove as much of the leg as possible
- B. The adequacy of the blood supply to the tissues
- C. The ease with which a prosthesis can be fitted
- D. The client's ability to walk with a prosthesis
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
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The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.
The nurse is reviewing acetaminophen (APAP) toxicity with students. The nurse should remind students that the maximum acetaminophen dosage for an adult is
- A. 2,000 mg per day
- B. 4,000 mg per day
- C. 5,000 mg per day
- D. 6,000 mg per day
Correct Answer: B
Rationale: The maximum recommended adult dose of acetaminophen is 4,000 mg per day to avoid liver toxicity.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
When assessing a client who has had spinal anesthesia, which of the following would the nurse expect to find?
- A. The client feels pain before moving the legs.
- B. The blood pressure is significantly increased.
- C. Sensation returns to the toes first, then progresses to the perineal area.
- D. The client complains of a headache while in the lying position.
Correct Answer: C
Rationale: After spinal anesthesia, sensation typically returns distally (toes) first, progressing proximally (perineal area), as the anesthetic wears off in a predictable pattern.
One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:
- A. Arteries
- B. Capillaries
- C. Lymphatics
- D. Veins
Correct Answer: A
Rationale: Anxiety can trigger sympathetic nervous system activation, causing arterial vasoconstriction, which worsens ischemia in PVD. Reducing anxiety helps maintain arterial dilation and blood flow. Capillaries, lymphatics, and veins are less affected by this mechanism.