Nokea
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Ventricular arrhythmias
- D. Loss of peripheral pulses
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
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A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Notify the physician immediately
- B. Hold the morning lithium dose and continue to observe the client
- C. Administer the morning lithium dose as scheduled
- D. Obtain an order for benztropine (Cogentin)
Correct Answer: C
Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.
Which type of insulin can be administered by a continuous IV drip?
- A. Humulin N
- B. NPH insulin
- C. Regular insulin
- D. Lente insulin
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be administered IV.
At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
- A. Reinforce an incompetent cervix
- B. Repair the amniotic sac
- C. Evaluate cephalopelvic disproportion
- D. Dilate the cervix
Correct Answer: A
Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.