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The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 90 bpm.
- C. Facial flushing and itching.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
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The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
- A. I can only wear cotton socks.'
- B. I cannot go barefoot around my house.'
- C. I will trim corns and calluses regularly.'
- D. I should ask a family member to inspect my feet daily.'
Correct Answer: C
Rationale: I will trim corns and calluses regularly.' Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
The nurse is caring for a client with a history of hemophilia.
- A. Which intervention is most important for a client with hemophilia experiencing joint pain?
- B. Administer factor replacement therapy.
- C. Apply warm compresses to the joint.
- D. Encourage active range-of-motion exercises.
- E. Administer oral analgesics.
Correct Answer: A
Rationale: Factor replacement therapy stops bleeding in hemophilia, relieving joint pain from hemarthrosis. Cold compresses are used, exercise worsens bleeding, and analgesics are supportive.
The nurse is caring for clients in the diabetic clinic.
Which of the following clients should the nurse see FIRST?
- A. A client with sunken eyeballs and a fruity breath odor.
- B. A client who complains of pain in his calves when he exercises.
- C. A client who states that she drinking liquids frequently and is always hungry.
- D. A client says that she is having difficulty sleeping and cries frequently.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-indicates diabetic ketoacidosis; treat with normal saline and regular insulin (2) suggestive of intermittent claudication, not an emergency situation (3) suggestive of hyperglycemia, should assess blood sugar (4) psychosocial issues, physical takes priority