Nokea
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy
- B. Contraction
- C. Gangrene
- D. Rubor
Correct Answer: C
Rationale: A black great toe in a client with PVD likely indicates gangrene, resulting from tissue necrosis due to severe ischemia from arterial occlusion. Atrophy causes muscle wasting, contraction is not a relevant term, and rubor refers to reddish discoloration, not black.
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The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These traffic control measures are designed to:
- A. Protect the privacy of clients.
- B. Prevent electrical sparks that could ignite the anesthetic gases.
- C. Separate the family from the surgical team to prevent distraction of the client.
- D. Provide for an aseptic environment to prevent infection.
Correct Answer: D
Rationale: Restricting access to the operating room maintains an aseptic environment, reducing the risk of surgical site infections by limiting contamination.
A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
- A. Percuss the abdomen to note resonance and tympany.
- B. Percuss the liver to note lack of dullness.
- C. Monitor the vital signs for fever, tachypnea, and bradycardia.
- D. Assess presence of polyphagia and polydipsia.
- E. Auscultate bowel sounds to note frequency.
Correct Answer: B,C
Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze
The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive 4 year old child. Which therapeutic action should the nurse take?
- A. Draw a "magic circle" on the area before the injection.
- B. Have another nurse hold down the child.
- C. Apply EMLA cream to the area immediately before the injection.
- D. Administer the medication right after the child's nap.
Correct Answer: D
Rationale: Administering after a nap can reduce anxiety and discomfort in a child, as they are likely to be calmer.
As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
Which factor besides the degree of neutropenia does the nurse assess in determining the client's risk of infection?
- A. Length of time neutropenia has existed.
- B. Health status before neutropenia.
- C. Body build and weight.
- D. Resistance to infection in childhood.
Correct Answer: A
Rationale: The duration of neutropenia significantly affects infection risk, as prolonged neutropenia increases exposure to pathogens. Pre-existing health status, body build, and childhood resistance are less directly relevant to current infection risk.