Nokea
The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
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A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply.
- A. Wear knee-high hose to prevent edema.
- B. Soak and wash the feet daily using cool water.
- C. Use commercial removers for corns or calluses.
- D. Use over-the-counter preparations to treat ingrown nails.
- E. Apply lanolin or baby oil if dryness is noted along the feet.
- F. Pat the feet dry thoroughly after washing and dry well between toes.
Correct Answer: E,F
Rationale: The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters.
The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.
A client with a known history of panic disorder comes to the emergency department and states to the nurse, 'Please help me. I think I'm having a heart attack.' What is the priority nursing action?
- A. Assess the client's vital signs.
- B. Encourage the client to use relaxation techniques.
- C. Identify the manifestations related to the panic disorder.
- D. Determine what the client's activity involved when the pain started.
Correct Answer: A
Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder for these signs and symptoms. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority.
A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial?
- A. Obtain baseline arterial blood gases.
- B. Obtain baseline pulse oximetry levels.
- C. Apply the mask to the face with a snug fit.
- D. Remove the mask for deep breathing exercises.
Correct Answer: C
Rationale: The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.