Herbert, a 45-year-old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
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Solution
Bleeding from ears
Option C: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns?
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Solution
Upper trunk
Option D: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
Mario has burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
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Solution
28 gtt/min
Option B: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
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Solution
Administer Kayexalate
Option A: Kayexalate, a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
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Solution
Keep the irrigating container less than 18 inches above the stoma.”
Option B: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.
Norma, with recent colostomy, expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
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Solution
Avoid foods that in the past caused flatus.
Option C: Foods that bothered a person preoperatively will continue to do so after a colostomy.
Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
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Solution
Leukopenia
Option C: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.
Ricardo was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:
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Solution
Liver Disease
Option A: The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.
Matilda, with hyperthyroidism, is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
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Solution
Decrease the size and vascularity of the thyroid gland.
Option D: Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.
The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:
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Solution
Pain
Option A: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by urethral distention and smooth muscle spasm; relief from pain is the priority.