Nokea
The nurse finds small, fluid-filled lesions on the margins of the client’s surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence?
- A. These were caused by the cautery unit in the operating room.
- B. These are papular wheals from herpes zoster.
- C. These are blisters from the tape used to anchor the dressing.
- D. These macular lesions are from a latex allergy.
Correct Answer: C
Rationale: Tape blisters are common around surgical dressings due to skin irritation. Cautery causes burns, herpes zoster is unrelated, and latex allergies cause diffuse reactions.
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Which nursing action is appropriate while the client is being transported?
- A. The nurse leaves the traction as is.
- B. The nurse removes the weights during the transport.
- C. The nurse rests the weights on the end of the bed.
- D. The nurse takes the client's leg out of the traction.
Correct Answer: B
Rationale: Removing the weights during transport prevents unintended movement or injury while maintaining the leg's position. Leaving traction as is or resting weights risks disrupting alignment, and removing the leg negates traction benefits.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.
Which laboratory test value, if elevated, is the best diagnostic indicator of rheumatoid arthritis?
- A. Erythrocyte sedimentation rate (ESR)
- B. Partial thromboplastin time (PTT)
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: An elevated ESR indicates inflammation, a hallmark of rheumatoid arthritis, making it a key diagnostic marker. PTT and BUN are unrelated to rheumatoid arthritis diagnosis.
The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented?
- A. Assess ability to void and log roll the client every two (2) hours.
- B. Medicate with IV steroids and keep the bed in a Trendelenburg position.
- C. Place sandbags on each side of the head and give cathartic medications.
- D. Administer IV anticoagulants and place on O2 at eight (8) L/min.
Correct Answer: A
Rationale: Post-lumbar laminectomy, assessing voiding prevents urinary retention, and log rolling maintains spinal alignment. Steroids/Trendelenburg, sandbags/cathartics, and anticoagulants/O2 are inappropriate without specific indications.
The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.