Nokea
The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
- A. Redness or inflammation of the tissue.
- B. Mottling or graying of the tissue.
- C. The client states that she feels a burning and tingling sensation in the area.
- D. The client states that she feels a numbness and a cold sensation in the area.
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.
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A family member of a client who has sustained an electrical burn states, 'I don't understand why he has been here a week. The burn does not look that bad.' Which of the following responses by the nurse is BEST?
- A. Electrical burns are more prone to infection.
- B. Electrical burns are always much worse than they look on the outside.
- C. Cardiac monitoring is important because electrical burns affect cardiac function.
- D. Electrical burns can be deceptive because underlying tissue is also damaged.
Correct Answer: D
Rationale: electrical burn injuries are typically more injurious to underlying tissue such as nerve and vascular tissue, which require complex and timely treatment
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 2,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³. Which of the following nursing diagnoses is MOST appropriate for this patient?
- A. Decreased cardiac output.
- B. Ineffective thermoregulation.
- C. Risk for injury.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: due to low platelet count, normal platelets 150,000-400,000/mm³, decrease causes problems with blood clotting
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea