Nokea
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
- A. impaired skin integrity
- B. Alteration in activity tolerance
- C. Impaired tissue perfusion
- D. Alteration in body image
Correct Answer: C
Rationale: Impaired tissue perfusion is the priority because varicose veins, ulcerations, and edema suggest poor blood flow, which can lead to worsening complications. Addressing perfusion improves skin integrity and prevents further deterioration, making it more critical than activity tolerance or body image.
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A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
- A. Stop the infusion of blood,
- B. Inform the provider.
- C. Obtain a urine specimen.
- D. Notify the laboratory.
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
- A. Wash with plain soap and water.
- B. sit in the sun for 10 min per day.
- C. Apply moist heat.
- D. Apply hydrating lotions.
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
A nurse is caring for a client with a chronic wound. Which of the following is a potential complication of a chronic wound?
- A. Electrolyte abnormalities
- B. Altered hemoglobin ATC
- C. Psychological distress
- D. Fluid volume overload
Correct Answer: C
Rationale: Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities. Electrolyte abnormalities are not typically a direct complication unless associated with severe infections or extensive fluid loss, which is uncommon. The wound itself does not directly alter hemoglobin A1C, which measures long-term blood glucose control. Fluid volume overload is not a direct complication of chronic wounds.
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
- A. Wash with plain soap and water.
- B. sit in the sun for 10 min per day.
- C. Apply moist heat.
- D. Apply hydrating lotions.
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
- A. Endolymph fluid provides protection to the structures of the inner ear.
- B. Sanguineous fluid provides protection to the structures of the inner ear.
- C. Aqueous humor provides protection to the structures of the inner ear.
- D. Vitreous humor provides protection to the structures of the inner ear.
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.