Nokea
The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse should take which action first in the care of this wound?
- A. Prepare for suturing the area.
- B. Determine when the client last had a tetanus vaccine.
- C. Cleanse the wound by flushing with sterile normal saline.
- D. Apply direct pressure to the laceration to stop the bleeding.
Correct Answer: D
Rationale: In the presence of active bleeding from a scalp laceration, the priority is to control the bleeding to prevent further blood loss and stabilize the client. Applying direct pressure to the laceration is the most effective initial action to achieve this. Preparing for suturing, determining tetanus vaccine status, and cleansing the wound are important but secondary actions that follow after bleeding is controlled.
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A multidisciplinary team working with the spouse of a home care client who has end-stage liver failure is teaching the spouse about pain management. Which statement by the spouse indicates the need for further teaching?
- A. My husband can use breathing exercises to control pain.
- B. I will help prevent constipation with increased fluids.
- C. If the pain increases, I will report it to the nurse promptly.
- D. The medication causes very deep sleep that my husband needs.
Correct Answer: D
Rationale: In the client with liver disease, the ability to metabolize medication is affected. A decreased level of consciousness is a potential clinical indicator of medication overdose, as well as fluid, electrolyte, and oxygenation deficiencies; thus, the nurse teaches the client's spouse about the differences between sleep related to pain relief and a deteriorating change in neurological status. Options 1, 2, and 3 all indicate an understanding of suitable steps to be taken in pain management.
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
- A. Widened pulse pressure
- B. Unilateral motor weakness
- C. Unilateral slowing of pupil response
- D. A decline in the level of consciousness
Correct Answer: D
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply.
- A. Vital signs
- B. Bilateral lung sounds
- C. Pulse in the affected extremity
- D. Level of pain in the affected leg
- E. Skin color of the affected extremity
- F. Capillary refill of the affected toes
Correct Answer: C,D,E,F
Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
- A. Covering the back dressing with a binder
- B. Placing the infant in a head-down position
- C. Strapping the infant in a baby seat sitting up
- D. Elevating the head with the infant in the prone position
Correct Answer: D
Rationale: Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial side-lying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity.