Nokea
The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
- A. Red skin with edema in the nail beds.
- B. Black fingertips surrounded by an erythematous rash.
- C. A white appearance to the skin that is insensitive to touch.
- D. A pink edematous hand.
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (Choice A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (Choice B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (Choice D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.
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A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
- A. Friction rub.
- B. Intermittent claudication.
- C. Cardiac murmur.
- D. Dependent rubor.
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice A) is more indicative of pericarditis, intermittent claudication (choice B) is associated with peripheral arterial disease, and dependent rubor (choice D) is seen in chronic arterial insufficiency. Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
- A. Hypervolemia.
- B. Hyperkalemia.
- C. Low hemoglobin.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (A) is less likely due to fluid shifts, low hemoglobin (C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (D) is not a common laboratory finding in this scenario.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.