The client has returned from surgery following a below the knee amputation (BKA). The residual limb is covered with a compression dressing. Immediately upon return from surgery, the dressing is dry. Thirty minutes later, a small amount of bloody drainage is noted on the dressing. What should be the nurse's priority action at this time?

Change the dressing

Notify the physician

Lower the head of the bed

Mark the area of drainage, time and date

Answer and Explanation

The Correct Answer is D

A.   While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B.   While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C.   Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D.   Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

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Correct Answer is ["A","B"]

Explanation

A. Limited access to fresh fruits and vegetables can contribute to poor dietary habits, which are linked to obesity and diabetes. Communities with food deserts often have higher rates of diabetes due to reduced access to nutritious food, leading to diets high in processed and unhealthy foods.
B. Living in disadvantaged communities is associated with increased diabetes prevalence and complications. Factors such as lower socioeconomic status, limited access to healthcare, poor health education, and environmental stressors can exacerbate health issues, including diabetes.
C. Having adequate health insurance is generally correlated with better health outcomes, including access to preventive care, regular monitoring, and treatment for diabetes. It does not contribute to increased prevalence or complications; rather, it mitigates them.

D. While certain viral infections have been studied for their potential role in triggering autoimmune diabetes (such as Type 1 diabetes), viral infections themselves are not a social inequity and do not directly correlate with increased diabetes prevalence in the same way that socioeconomic factors do.
E. Autoimmune disorders can be associated with Type 1 diabetes and some cases of Type 2 diabetes; however, this option does not reflect a social inequity. Instead, autoimmune disorders are more related to individual health conditions and genetics.

A. makes the blood less thick and easier to flow." B. does not thin the blood: it prevents new clots from forming." C. decreases the number of platelets so the blood clots more slowly." D. dissolves the clot and decreases the formation of platelets."

Correct Answer is B

Explanation

A. Heparin does not actually "thin" the blood in the sense of reducing viscosity. Instead, it works by inhibiting certain factors in the coagulation cascade, preventing clot formation. Thus, this response does not accurately describe how heparin functions.

B. Heparin works by activating antithrombin III, which inhibits thrombin and factor Xa, thereby preventing the formation of new clots. It does not dissolve existing clots but helps to prevent the enlargement of existing ones and the formation of new clots.
C. Heparin does not decrease the number of platelets; rather, it interferes with the clotting process by inhibiting specific clotting factors. Platelets may still be present, but their ability to form clots is inhibited by the action of heparin.
D. Heparin does not dissolve existing clots; that function is typically performed by thrombolytic agents. Heparin primarily prevents new clot formation and the extension of existing clots. Additionally, it does not decrease platelet formation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is aware that which of the following social inequities are correlated with increased diabetes prevalence & more severe complications of diabetes? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B"]

Explanation

The client diagnosed with deep vein thrombosis asks the nurse, "How does heparin work to help with my blood clot?" Which response is most accurate? "Heparin:

Correct Answer is B

Explanation

A client is receiving gentamicin every 12 hours IVPB for an infection. The nurse has administered the 0800 dose, which is prescribed to run over 1 hour. The physician prescribed peak and trough levels to be drawn. The nurse recognizes that the peak level will be drawn at

A client is ordered 450 ml of Normal Saline Solution over 3 hours. The drop factor on the IV tubing is 15 drops per ml. At what rate should the nurse regulate the IV?

A client with Type 2 diabetes is brought into the emergency room in an unresponsive state. A diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) is made. The nurse prepares for the administration of which initial therapy?

A client's insulin dosage is 16 units of regular insulin in the morning. The client should be taught to expect the insulin peak within:

What factors in the history of a client with schizoaffective disorders puts the client at higher risk for type 2 diabetes? (SELECT ALL THAT APPLY)

The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:

A client screened for diabetes has a fasting plasma glucose level of 120 mg/dl. The nurse will plan to teach the client about