Nokea
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution
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The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse is caring for a client who is suffering from severe anxiety. What must the client do first when learning to deal with his anxiety?
- A. Recognize that he is feeling anxious
- B. Identify the situations that precipitated his anxiety
- C. Understand the reason for his anxiety
- D. Select a strategy to use to help him cope with his anxiety
Correct Answer: A
Rationale: Recognizing anxiety is the first step in managing it, enabling the client to address triggers, reasons, and coping strategies sequentially.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.
The nurse is caring for a client with a history of leukemia.
- A. Which laboratory finding is most concerning for a client with leukemia?
- B. White blood cell count of 50,000/mm³.
- C. Platelet count of 20,000/mm³.
- D. Hemoglobin of 11.0 g/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia, risking life-threatening bleeding in leukemia. Elevated WBC is expected, low hemoglobin is common, and normal potassium is unremarkable.