Nokea
When should the nurse conduct an Allen's test?
- A. When obtaining pulmonary artery pressures
- B. To assess for the presence of a deep vein thrombus in the leg
- C. Just before arterial blood gases are drawn peripherally
- D. Prior to attempting a cardiac output calculation
Correct Answer: C
Rationale: The correct time to conduct an Allen's test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen's test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen's test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen's test is not done specifically before attempting a cardiac output calculation.
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A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?
- A. High risk for infection related to subclavian catheter
- B. High risk of injury related to ambulation
- C. Knowledge deficit related to a high-protein diet
- D. Hygiene self-care deficit related to uremic frost
Correct Answer: D
Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.
The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?
- A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
- B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
- C. Review his glycosylated hemoglobin level 3 months after the teaching session.
- D. Have the adolescent list the steps for safe insulin administration.
Correct Answer: C
Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.
While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
- A. Apply a pressure dressing around the chest tube insertion site
- B. Assess the client for allergies to topical cleaning agents
- C. Measure the area of swelling and crackling
- D. Administer an oral antihistamine per PRN protocol
Correct Answer: A
Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.
The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?
- A. Inspect skin for redness
- B. Use a residual limb shrinker
- C. Apply alcohol to the stump after bathing
- D. Wash the stump with soap and water
Correct Answer: D
Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.
When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
- A. 42
- B. 38
- C. 48
- D. 50
Correct Answer: A
Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.