Nokea
A patient several days after an above-knee amputation (AKA).
Which of the following symptoms would be characteristic of an infected stump wound?
- A. The patient is anxious and restless.
- B. There is a small amount of dark drainage on the dressing.
- C. The patient complains of persistent pain at the operative site.
- D. The skin is cool above the operative site.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct-pain is characteristic of inflammation and infection (4) warm skin above site would indicate infection
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The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
- A. Eat large amounts of rice.
- B. Increase the amount of fruits and vegetables in your diet.
- C. Ask the doctor for a prescription for a drug such as diphenoxylate hydrochloride and atropine sulfate (Lomotil).
- D. Drink fluids only with meals.
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
A client receiving oxygen at 6 L/min.
What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
- A. The patient's position in bed and the respiratory rate.
- B. The site used to obtain the blood specimen.
- C. The use of supplemental oxygen.
- D. The patient's diagnosis and blood type.
Correct Answer: C
Rationale: Strategy: Think about each answer choice and how it relates to blood gases. (1) unnecessary to document positioning (2) unnecessary to document site used (3) correct-necessary for accurate Test results (4) unnecessary to document blood type, should document diagnosis
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
- A. What is the best nursing intervention for a 14-year-old with an acute exacerbation of ulcerative colitis?
- B. Encourage her mother to room in with her.
- C. Provide information on the hospital school program.
- D. Ask if she would like to have visits from friends.
- E. Involve her in planning her daily schedule.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
- A. Sexually transmitted infection
- B. Exposure to teratogens
- C. Maternal hypertension
- D. Chromosomal abnormalities
Correct Answer: C
Rationale: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.