Nokea
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. Hematocrit.
- B. Platelet count.
- C. White blood cell (WBC) count.
- D. Blood pH level.
Correct Answer: C
Rationale: WBC count indicates infection, as purulent drainage suggests bacterial colonization requiring prompt intervention.
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The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure reading will be less than 160/90 mm Hg.
- B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The nurse will encourage the client to walk thirty minutes every day.
Correct Answer: B
Rationale: A blood pressure goal of less than 140/80 mm Hg is specific and aligns with cardiovascular health targets, addressing blurred vision linked to hypertension.
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Encourage the client to splint the Incision with a pillow to cough and deep breathe.
- C. Medicate for pain and monitor vital signs according to protocol.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: C
Rationale: Pain medication addresses tachycardia and tachypnea likely caused by postoperative pain, stabilizing vital signs.
Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. The client reports that symptoms seem worse when outdoors and when exercising.
Correct Answer: A,B
Rationale: The ineffective use of the rescue inhaler indicates a severe asthma attack requiring intervention, and worsening symptoms with exercise suggest environmental triggers needing management.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
History and Physical
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use recreational drugs. Typically, he drinks 2 to 3 dark beers nightly.
The healthcare provider is considering medications to treat the client's gout.
A 59-year-old male client presents to the clinic reporting pain in the right great toe. For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.
- A. Colchicine: Reduces inflammation.
- B. Prednisone: Reduces inflammation.
- C. Naproxen: Reduces pain and inflammation.
- D. Allopurinol: Lowers uric acid levels.
Correct Answer: A,B,C,D
Rationale: Colchicine and prednisone reduce inflammation, naproxen alleviates pain and inflammation, and allopurinol prevents uric acid buildup, addressing both acute and chronic gout management.