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Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
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Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
- A. Apply zinc oxide to the surrounding skin
- B. Use a binder to hold the dressing in place
- C. Support the arm and the shoulder with pillows
- D. Instruct the client not to shave the axillary hair on the side with abscess
Correct Answer: A
Rationale: Applying zinc oxide to the surrounding skin can help protect it from becoming macerated due to irritating drainage or wound compresses. Zinc oxide acts as a barrier that helps prevent moisture from affecting the skin, thus reducing the risk of maceration. It provides a protective layer and promotes healing by keeping the affected area dry and free from further irritation. It is an effective intervention to maintain skin integrity and promote optimal wound healing in clients with a breast abscess.
Mrs. Go is suspected of experiencing respiratory distress from a left-sided pneumothorax. She should be positioned:
- A. in a semi-fowler's position
- B. trendelenburg position
- C. prone position
- D. on the right side
Correct Answer: A
Rationale: Mrs. Go, who is suspected of experiencing respiratory distress from a left-sided pneumothorax, should be positioned in a semi-fowler's position. This position involves elevating the head of the bed to approximately 30 to 45 degrees. Placing the patient in a semi-fowler's position helps improve lung expansion, facilitates breathing, and promotes optimal oxygenation. It can also help prevent the collapse of the affected lung and assist in reducing the symptoms associated with pneumothorax. Trendelenburg position (B) and prone position (C) are not recommended for pneumothorax as they can worsen the condition by putting additional pressure on the affected lung. Placing the patient on the right side (D) would not specifically address the respiratory distress caused by a left-sided pneumothorax. Therefore, the most appropriate position for Mrs. Go in this situation is the semi-fowler's position.
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
- A. respiratory compromise related to inhalation of smoke
- B. pneumonia related to prolonged bedrest
- C. fat embolism syndrome related to femur fracture
- D. hypovolemic shock related to multiple trauma
Correct Answer: C
Rationale: The symptoms described in the scenario - dyspnea, tachypnea, crackles in lung fields, and coughing up thick, white sputum - are indicative of fat embolism syndrome (FES), which occurs as a complication of long bone fractures like the femur fracture in this case. FES is characterized by the release of fat droplets into the bloodstream, which can then travel to the lungs and cause respiratory distress. The onset of symptoms typically occurs within 24-72 hours after the initial injury, making it a likely cause for Ms. Slovenski's condition. This is a medical emergency that requires prompt recognition and intervention to prevent further complications. The other options (A, B, and D) do not align with the clinical picture presented in the scenario and are less likely causes of her current symptoms.
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- A. Wash the radiation site vigorously with soap and water to remove dead cells.
- B. Eat a diet high in protein and calories to optimize tissue repair.
- C. Apply coo! compresses to the radiation site to reduce edema,
- D. Drink warm fluids throughout the day to relieve discomfort in swallowing
Correct Answer: B
Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.
What should be included in the plan of care for a preschool-age child who is admitted in a vasoocclusive sickle cell crisis (pain episode)?
- A. Pain management
- B. Administration of heparin
- C. Factor VIII replacement
- D. Electrolyte replacement
Correct Answer: A
Rationale: Pain management is a crucial component in the plan of care for a preschool-age child admitted with a vasoocclusive sickle cell crisis. Sickle cell disease causes blood vessels to become blocked, leading to ischemia and pain. Managing pain promptly and effectively is necessary to improve the child's comfort level and prevent complications. Pain management strategies typically involve the use of analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, tailored to the child's age and weight. Additionally, non-pharmacological interventions like distraction techniques and positioning can help in reducing pain and promoting relaxation in children during a sickle cell crisis.