Nokea
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
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A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
- A. Surgical repair of a diseased coronary artery
- B. Placement of an automatic internal cardiac defibrillator
- C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
- D. Non-invasive radiographic examination of the heart
Correct Answer: C
Rationale: PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization.
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
- A. Capillary refill less than 3 seconds
- B. Pale mucous membranes
- C. Respirations 20 breaths per minute
- D. Complaints of fatigue when ambulating
Correct Answer: A
Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.
The nurse aus.Concurrent with the above question, the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
- A. Administer an inhaled bronchodilator
- B. Check marked insertion depth of the tube
- C. Request a prescription for a diuretic
- D. Start the client on incentive spirometry
Correct Answer: C
Rationale: Crackles and diminished breath sounds in the lung bases postpartum suggest fluid overload or pulmonary edema, possibly due to prolonged labor or excessive IV fluids. Requesting a diuretic is appropriate to reduce fluid overload. Bronchodilators are for bronchospasm, checking tube depth is irrelevant without an endotracheal tube, and incentive spirometry is less urgent.