Nokea
The primary goal for the client with Buerger's disease is to prevent:
- A. Embolus formation
- B. Fat embolus formation
- C. Thrombophlebitis
- D. Gangrene
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
You may also like to solve these questions
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
- A. To the client from sources outside the client's environment.
- B. From the client to health care personnel, visitors, and other clients.
- C. By using special techniques to dispose of contaminated materials.
- D. By using special techniques to handle the client's linens and personal items.
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours
- E. Request an alternating-pressure mattress
Correct Answer: C,D,E
Rationale: The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary
The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?
- A. Peripheral nerve block
- B. Spinal anesthesia
- C. General Anesthesia
- D. Local Anesthesia
Correct Answer: C
Rationale: General anesthesia is typically used for young children undergoing procedures like incision and drainage to ensure safety and comfort.
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
- A. Check the patient-controlled analgesia (PCA) pump function.
- B. Adjust the epidural catheter.
- C. Assess vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.