Giddens Concepts for Nursing Practice Test Bank

Correct Answer: A

Rationale: A. Elevate the stump: Elevation of the stump helps to reduce swelling and improve blood circulation, aiding in the healing process after the amputation.

Correct Answer: A

Rationale: A. Elevate the stump: Elevation of the stump helps to reduce swelling and improve blood circulation, aiding in the healing process after the amputation.

Correct Answer: A

Rationale: Given the client's history of type II diabetes mellitus, chronic hypertension, and recent myocardial infarction, the most likely type of shock for the nurse to be prepared to treat in this client is cardiogenic shock. Cardiogenic shock occurs when the heart is unable to pump effectively, leading to inadequate perfusion of vital organs. This can be a complication of myocardial infarction, as damage to the heart muscle can impair its ability to pump blood effectively. Patients with a history of diabetes and hypertension are at increased risk for cardiovascular diseases, such as myocardial infarction, which can lead to cardiogenic shock. Symptoms of cardiogenic shock include hypotension, tachycardia, cool and clammy skin, and altered mental status. Treatment may involve medications to support cardiac function, such as inotropes, and interventions to improve oxygen delivery, such as oxygen therapy and fluid administration.

Correct Answer: B

Rationale: In the context of Ineffective Peripheral Tissue Perfusion in a client with disseminated intravascular coagulation (DIC), administering oxygen is the most appropriate intervention. DIC is a serious condition characterized by widespread clotting in small blood vessels throughout the body, leading to tissue ischemia and inadequate perfusion. Administering oxygen can support tissue oxygenation and improve perfusion to the peripheral tissues, helping to alleviate the effects of decreased blood flow and oxygen delivery caused by DIC. Oxygen therapy can help optimize oxygen levels in the blood and tissues, promoting better tissue perfusion and overall patient outcomes. Monitoring oxygen saturation and ensuring adequate oxygen delivery are crucial aspects of managing tissue perfusion in clients with DIC.

Correct Answer: C

Rationale: Following surgery, a patient not voiding for 12 hours raises concerns for urinary retention, especially if the patient was catheterized during the surgical procedure. With urinary retention, the bladder can become distended and palpating for bladder distention can help determine if the patient is experiencing this issue. If the bladder is distended, interventions may be needed to address the urinary retention to prevent complications such as urinary tract infection or bladder distention-related discomfort. The other assessment options (percuting for gastric tympany, auscultating for bowel sounds, inspecting for edema of the urethra) are not as relevant in assessing a patient's urinary status post-surgery.