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What is the best answer that describes a mechanical defense in a client?
- A. Enzymes
- B. Antibodies
- C. Skin and mucous membranes
- D. Secretions
Correct Answer: C
Rationale: The correct answer is C because skin and mucous membranes act as physical barriers to prevent pathogen entry.
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A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?
- A. “The client's low phosphorus is probably due to malnutrition.”
- B. “The client is just worn out from not getting enough rest.”
- C. “The client's skeletal muscles are weak because of the low phosphorus.”
- D. “The client will do more for herself when her phosphorus is normal.”
Correct Answer: C
Rationale: Low phosphorus levels impair energy production in cells, leading to muscle weakness and fatigue, which explains the need for assistance.
Which type of intravenous fluid draws fluid into the intravascular compartment from the more dilute areas in the cells and interstitial spaces?
- A. Isotonic fluid
- B. Hypertonic fluid
- C. Hypotonic fluid
- D. Colloid fluid
Correct Answer: B
Rationale: The correct answer is B because hypertonic fluids draw water from cells into the bloodstream, increasing intravascular volume.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, the medical-surgical nurse anticipates the next step in the immediate care of this patient will include
- A. administering tissue plasminogen activator.
- B. obtaining a CT scan of the head without contrast.
- C. obtaining a neurosurgical consultation.
- D. preparing for carotid Doppler ultrasonography.
Correct Answer: B
Rationale: A CT scan is essential to differentiate between ischemic and hemorrhagic stroke.
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.