Nokea
The nurse cares for a client who sustained full-thickness thermal burns to 30% of their total body surface area (TBSA). Which of the following initial laboratory values would be expected?
- A. Potassium 5.6 mEq/L (mmol) [3.5-5 mEq/L]
- B. Hematocrit 30% (0.30 L/L) [ Male: 42-52% Female: 37-47%, 0.38-0.50 L/L]
- C. BUN 14 mg/dL (5.0004 mmol/L)[10-20 mg/dL, 2.1-8.0 mmol/L]
- D. Glucose 89 mg/dL (4.94 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: A
Rationale: Hyperkalemia (elevated potassium) is expected initially due to cell destruction from burns releasing potassium into the bloodstream.
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Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.
The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G
Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?
- A. Document the finding and continue with routine care
- B. Apply a topical antibiotic ointment to the affected areas
- C. Conduct and document an emergency assessment
- D. Perform and document a focused assessment of skin integrity
Correct Answer: D
Rationale: Reddened areas over bony prominences suggest early pressure ulcers, requiring a focused skin integrity assessment to guide interventions.
The nurse is performing a physical assessment on a client who has a round, non-tender nodule on the left wrist. It would be appropriate for the nurse to identify this as a
- A. janeway lesion
- B. bouchard node
- C. ganglion cyst
- D. pilar cyst
Correct Answer: C
Rationale: A round, non-tender nodule on the wrist is characteristic of a ganglion cyst, a benign fluid-filled sac.