Nokea
Which of the following represents the most appropriate nursing intervention for a client with pruritus caused by cancer or the treatment?
- A. Administration of antihistamines.
- B. Steroids.
- C. Silk sheets.
- D. Medicated cool baths.
Correct Answer: D
Rationale: Medicated cool baths soothe the skin and reduce pruritus, a common symptom in cancer patients, without the systemic effects of antihistamines or steroids.
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An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
The nurse is reading the results of a tuberculin skin test (see fi gure). The nurse should interpret the results as:
- A. Negative
- B. Needing to be repeated.
- C. Positive.
- D. False.
Correct Answer: C
Rationale: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purifi ed protein derivative (PPD) by measuring the size of the fi rm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a fi rm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false.
The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. This observation should prompt the nurse to do which of the following?
- A. Continue monitoring as usual; this is expected.
- B. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle.
- C. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours.
- D. Drain half of the water from the water-seal chamber.
Correct Answer: B
Rationale: Constant gentle bubbling in the water-seal column suggests an air leak; checking connectors identifies the source. Expected bubbling is intermittent. Adjusting suction or draining water is inappropriate.
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube?
- A. Electrical burns of the hands and arms causing arrhythmias.
- B. Thermal burns to the head, face, and airway resulting in hypoxia.
- C. Chemical burns on the chest and abdomen.
- D. Secondhand smoke inhalation.
Correct Answer: B
Rationale: Thermal burns to the head, face, and airway can cause swelling and obstruction, leading to hypoxia and requiring airway management like endotracheal intubation or tracheostomy.
A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2°C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider:
- A. Continues the pentoxifylline
- B. Increases the I.V. fluids
- C. Restarts the metoprolol
- D. Resumes the furosemide
Correct Answer: C
Rationale: SBAR: Situation€”postop day 1, heart rate 132 bpm. Background€”aortobifemoral bypass, history of hypertension, on metoprolol preop. Assessment€”tachycardia suggests inadequate beta-blockade, other vitals stable. Recommendation€”restart metoprolol to control heart rate and blood pressure. Pentoxifylline is less urgent, fluids are adequate (urine output normal), and furosemide may cause dehydration.