A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will wear gloves when removing food from the freezer"

"I will take my medications at the first sign of an attack"

"I will try to anticipate and avoid stressful situations when possible"

"I will complete the smoking cessation program I started"

Answer and Explanation

The Correct Answer is B

A. "I will wear gloves when removing food from the freezer": This statement demonstrates understanding of the need to protect the hands from cold exposure, which can trigger Raynaud's disease symptoms. Wearing gloves when handling cold objects, such as food from the freezer, helps minimize the risk of a vasospastic episode.
B. "I will take my medications at the first sign of an attack": This statement indicates a misunderstanding of the appropriate use of medications for Raynaud's disease. While medications such as calcium channel blockers may be prescribed to prevent or reduce the frequency and severity of attacks, they are typically taken regularly as part of ongoing management rather than at the first sign of symptoms. This client may need additional education on the proper use of medications for Raynaud's disease.
C. "I will try to anticipate and avoid stressful situations when possible": Stress can exacerbate symptoms of Raynaud's disease by triggering vasospasm, so anticipating and avoiding stressful situations is a proactive strategy to help prevent attacks. This statement reflects an understanding of the importance of stress management in managing the condition.
D. "I will complete the smoking cessation program I started": Smoking is a significant risk factor for Raynaud's disease and can worsen symptoms by constricting blood vessels. Committing to a smoking cessation program demonstrates the client's recognition of the importance of lifestyle modifications in managing the condition.

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Correct Answer is A, C, B, D, E

Explanation

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.

Correct Answer is ["2"]

Explanation

Here's how we can find the desired flow rate:

Total volume to infuse (in minutes):
- We need to convert the infusion time from hours to minutes.
- Time (minutes) = Time (hours) x 60 minutes/hour
- Time (minutes) = 2 hours x 60 minutes/hour
- Time (minutes) = 120 minutes
Total volume to infuse (in mL):
- Given volume = 250 mL
Drop factor (gtts/mL):
- Given drop factor = 15 gtts/mL
Flow rate (gtts/minute):
- Flow rate = Total volume (mL) / Time (minutes) x Drop factor (gtts/mL)
- Flow rate = 250 mL / 120 minutes x 15 gtts/mL

To simplify the calculation, we can divide all values by 5 (as long as we perform the division on both sides of the equation, the answer won't change):

Flow rate = (250 mL / 5) / (120 minutes / 5) x (15 gtts/mL / 5)
Flow rate = 50 mL / 24 minutes x 3 gtts/mL
Flow rate = 2.0833... gtts/minute (round to nearest whole number)

Rounded flow rate (gtts/minute):
- Flow rate = 2 gtts/minute

Therefore, the nurse should adjust the flow rate to deliver approximately 2 gtts/minute.

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A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A, C, B, D, E

Explanation

Correct Answer is ["2"]

Explanation

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