Nokea
The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing?
- A. Apply a Kerlix roll and tape it to the skin.
- B. Apply a large, soft pad and tape it to the skin.
- C. Apply small Montgomery straps and tie the edges together.
- D. Apply a Kling roll and tape the edge of the roll onto the bandage.
Correct Answer: D
Rationale: Standard dressing technique includes the use of Kling rolls on circumferential dressings. With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps should not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway).
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An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is normal when which element is negative?
- A. Protein
- B. Glucose
- C. Red blood cells
- D. White blood cells
Correct Answer: C
Rationale: The adult with a normal CSF has no red blood cells in the CSF. Protein (15-45 mg/dL [0.15-0.45 g/L]) and glucose (50-75 mg/dL [2.8-4.2 mmol/L]) are normally present in CSF. The client may have small levels of white blood cells (0-5 cells/mcL [0-5 × 10^6/L]).
The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition?
- A. Endometriosis is known as primary dysmenorrhea.
- B. Endometriosis is what causes me the pain that occurs when I ovulate.
- C. Endometriosis is the condition that has caused me to stop menstruating.
- D. Endometriosis means that I have uterine tissue growing outside my uterus.
Correct Answer: D
Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes.
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.