Nokea
When dressing a severe burn to the right hand, it is important for the nurse to:
- A. Apply a wet-to-dry dressing for debridement
- B. Wrap each digit individually to prevent webbing
- C. Open blisters to allow drainage prior to dressing
- D. Allow the client to do as much of the dressing change as possible
Correct Answer: B
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
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The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?
- A. Pink-tinged
- B. Straw-colored
- C. Clear
- D. Dark amber
Correct Answer: D
Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.
After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?
- A. How the client tolerated the procedure.
- B. The length and intactness of the central line catheter.
- C. The amount of fluid left in the IV solution container.
- D. That a dressing was applied to the insertion site.
Correct Answer: B
Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PICC) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal. Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.
Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?
- A. The hematocrit is adversely affected due to increased vascular volume.
- B. AEDs can lead to blood dyscrasia as a side effect.
- C. AEDs may cause aplastic anemia and megaloblastic anemia.
- D. Some AEDs induce white blood cell reduction.
Correct Answer: B
Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
- A. Facial flushing
- B. A complaint of chest heaviness
- C. Heart rate increase of 10 beats/min
- D. Systolic blood pressure increase of 10 mm Hg
Correct Answer: B
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?
- A. Infection
- B. Incision
- C. Pain
- D. Tissue perfusion
Correct Answer: D
Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.