Nokea
Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?
- A. Fremitus
- B. Hyperresonance
- C. Dullness on percussion
- D. Decreased tactile fremitus
Correct Answer: C
Rationale: The correct answer is C: Dullness on percussion. In pneumonia, the affected lung tissue becomes consolidated, leading to dullness on percussion due to decreased air movement. The rationale behind this is that consolidation causes the air-filled lung tissue to become filled with fluid and inflammatory cells, impairing normal sound transmission upon percussion.
Incorrect choices:
A: Fremitus - Increased tactile fremitus is typically found in pneumonia due to the denser lung tissue, making this choice incorrect.
B: Hyperresonance - Hyperresonance is commonly found in conditions like emphysema with increased lung air volume, not in pneumonia.
D: Decreased tactile fremitus - This is contradictory as pneumonia usually presents with increased tactile fremitus due to the consolidated lung tissue.
Why should a nurse practice caution when changing the wound dressings of a client who underwent surgery?
- A. To avoid damaging new tissue.
- B. To avoid causing pain to the client.
- C. To fasten the wound healing.
- D. To avoid wound infection.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What health hazard is significant, particularly to patients with asthma?
- A. Alcoholism
- B. Asthma
- C. Peptic ulcer
- D. Peripheral vascular disease
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for a tracheal deviation.
- C. Administer oxygen to maintain saturations above 94%.
- D. Perform peak expiratory flow measurements.
Correct Answer: C
Rationale: The correct answer is C. Administer oxygen to maintain saturations above 94%. In asthma exacerbation, maintaining oxygen saturation is crucial to prevent hypoxia. Oxygen therapy helps improve oxygen delivery to tissues and organs. Administering salmeterol (choice A) may help with long-term management but is not an immediate priority. Tracheal deviation assessment (choice B) is not relevant to asthma exacerbation. Performing peak expiratory flow measurements (choice D) may be helpful for monitoring asthma severity but is not the priority in this acute situation.
While discussing factors causing emphysema with Mr. Puff, what major factor is he already aware of?
- A. Air pollution
- B. Repeated bronchial infections
- C. Cigarette smoking
- D. Hereditary
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.