Nokea
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
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A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should monitor the client for which of the following signs of overdose?
- A. Tachycardia.
- B. Weight gain.
- C. Cold intolerance.
- D. Bradycardia.
Correct Answer: A
Rationale: Tachycardia indicates levothyroxine overdose due to excessive thyroid hormone.
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.
Your client is receiving phototherapy. What nursing intervention would you implement for this client?
- A. Placing the client in the Trendelenburg position
- B. Monitoring the color of the stools
- C. Using a Hoyer lift for patient transfers
- D. Monitoring the arterial blood gases
Correct Answer: B
Rationale: Phototherapy, often used for jaundice, can affect stool color (e.g., green or loose stools in infants). Monitoring stool color helps assess treatment effects and complications.
You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?
- A. Case manager
- B. Collaborator
- C. Coordinator of care
- D. Advocacy
Correct Answer: D
Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.
Immediately after the client receives an injection of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?
- A. Ask the client to talk more about what he is feeling
- B. Reassure the client that it is normal to feel restless before a procedure
- C. Assess the client's vital signs
- D. Administer epinephrine
Correct Answer: C
Rationale: Restlessness, nervousness, and a feeling of impending doom after bupivacaine injection may indicate systemic toxicity or an allergic reaction, requiring immediate vital sign assessment to guide further action. Talking, reassurance, or administering epinephrine without assessment is premature.