Nokea
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
- A. Skin integrity
- B. Functional ability
- C. Heart sounds
- D. Pain scale
Correct Answer: A
Rationale: These assessments help determine the effectiveness of treatment in managing pain, skin lesions, and the client's ability to perform daily activities.
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A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
- A. Offer ice chips and oral clear liquids
- B. Verify pedal pulses using a doppler pulse device
- C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
- D. Evaluate the application of the splint to the left leg
Correct Answer: B
Rationale: These interventions assess and address potential vascular compromise, which is critical in a client with a fractured femur.
Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
- A. 5% glucose
- B. 10% glucose
- C. 15% glucose
- D. 17% glucose
Correct Answer: B
Rationale: A 10% glucose solution is safe for peripheral veins and provides adequate nutrition without causing irritation or damage.
Hereditary angioneurotic oedema (HANE):
- A. Deficiency of CI esterase occurs
- B. Can present as recurrent abdominal pain
- C. C4 is increased
- D. Androgen agonists are helpful in management
Correct Answer: A
Rationale: Deficiency of CI esterase occurs
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
- A. Pulmonary congestion
- B. Congenital heart defect
- C. Heart failure
- D. Systemic venous congestion
Correct Answer: C
Rationale: The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.
In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs?
- A. Transposition of the great vessels
- B. Aortic stenosis (AS)
- C. Coarctation of the aorta (COA)
- D. Tetralogy of Fallot (TOF)
Correct Answer: C
Rationale: COA causes increased blood pressure and strong pulses in the upper extremities with lower-than-expected BP and weak pulses in the lower extremities.