Nokea
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?
- A. Anxiety level of the client and family
- B. Presence of a MedicAlert card for the client to carry
- C. Knowledge of restrictions on postdischarge physical activity
- D. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
Correct Answer: D
Rationale: Ensuring the device is active and correctly programmed is critical for life-saving function.
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The nurse is applying Accuzyme papain-urea to a client diagnosed with a stage 3 pressure ulcer. Which intervention should the nurse implement?
- A. Cleanse the wound with hydrogen peroxide solution.
- B. Rub the papain cream directly into the wound.
- C. Apply 1/8-inch papain ointment to the pressure ulcer.
- D. Be sure that no medication is applied on viable tissue.
Correct Answer: C
Rationale: Accuzyme papain-urea is a debriding enzyme. Apply 1/8-inch thickness after cleansing (not with hydrogen peroxide, which inactivates it). Rubbing damages tissue, and it's safe for viable tissue.
In patients with extensive burns, edema occurs in both burned and unburned areas because of:
- A. catecholamine-induced vasoconstriction.
- B. decreased glomerular filtration.
- C. increased capillary permeability.
- D. loss of integument barrier.
Correct Answer: C
Rationale: Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema(third spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.
Which intervention should the nurse implement to prevent infection in a client with burn injuries?
- A. Ask all family members and visitors to perform hand hygiene before touching the client.
- B. Carefully monitor burn wounds when providing each dressing change.
- C. Clean equipment with alcohol between uses with each client on the unit.
- D. Allow family members to only bring the client plants from the hospital's gift shop.
Correct Answer: A
Rationale: Hand hygiene by all prevents infection transmission.
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?
- A. Prepare the patient for opening or bivalving of the cast.
- B. Obtain an order for a different analgesic.
- C. Encourage the patient to wiggle and move the fingers.
- D. Petal the edges of the patient's cast.
Correct Answer: A
Rationale: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.
What is the primary purpose of a whirlpool bath given to the patient with a stage III pressure ulcer?
- A. To prevent infection
- B. To stimulate granulation tissue growth
- C. To improve circulation in surrounding skin
- D. To provide moisture to the ulcer
Correct Answer: B
Rationale: The whirlpool acts as a type of debridement. It gets rid of the necrotic debris and stimulates granulation tissue growth.