Nokea
The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which of the following:
- A. Blood pressure and heart rate changes
- B. Gradual or acute loss of sensory and motor function
- C. Metabolic acidosis
- D. Swelling in the left lower extremity
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to loss of sensory (numbness) and motor function (weakness) in the affected limb. Monitoring for these changes is critical to detect progression and prevent tissue damage. Blood pressure/heart rate, metabolic acidosis, and swelling are less specific or late findings.
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The nurse has attended a staff development conference regarding patient-controlled analgesia. Which of the following statements by the nurse indicates effective understanding?
- A. A client may be prescribed a loading dose before they are able to activate their own prescribed dosage.
- B. PCAs are not recommended for individuals with acute pain.
- C. PCAs decrease the need for a client to have pain assessments.
- D. When a client receives a PCA via a continuous basal rate, it decreases their risk for adverse effects.
Correct Answer: A
Rationale: A loading dose is often used in PCA to achieve initial pain control before the patient begins self-administering doses. PCAs are suitable for acute pain, do not eliminate the need for pain assessments, and continuous basal rates may increase adverse effect risks.
Which of the following is the priority for a client in addisonian crisis?
- A. Controlling hypertension.
- B. Preventing irreversible shock.
- C. Preventing infection.
- D. Relieving anxiety.
Correct Answer: B
Rationale: Addisonian crisis is a life-threatening condition requiring urgent intervention to prevent irreversible shock due to adrenal insufficiency.
A client with Buerger's disease smokes two packs of cigarettes a day. Smoking cessation is critical or the client may lose the affected extremity. When helping a client change behavior, it is important to know the client's:
- A. Ability to attend support groups
- B. Goals of the treatment
- C. Perception of the negative behavior
- D. Motivation
Correct Answer: D
Rationale: Motivation is critical for behavior change, such as smoking cessation in Buerger's disease, as it drives the client's commitment to quit. Understanding motivation (e.g., desire to avoid amputation) guides tailored interventions. Support groups, treatment goals, and perception are secondary to motivation.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
- A. Review the results of culture and sensitivity testing of the wound.
- B. Look for the presence of a pressure dressing over the wound.
- C. Determine if the client has increased pain from exposed nerve endings.
- D. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.
Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy?
- A. Glycosuria.
- B. A 1- to 2-pound weight gain.
- C. Decreased appetite.
- D. Elevated temperature.
Correct Answer: D
Rationale: An elevated temperature after the first few days of TPN may indicate a complication like infection, particularly catheter-related. Glycosuria can occur with TPN but is managed, a small weight gain is expected, and decreased appetite is not a direct complication. CN: Pharmacological and parenteral therapies; CL: Analyze