Concepts for Nursing Practice Giddens Test Bank

Correct Answer: A

Rationale: A neurovascular assessment is performed to evaluate nerve function, circulation, and tissue perfusion. Pale, cold fingers indicate poor circulation, which can be a sign of compromised blood flow from the cast causing decreased oxygen supply to the tissues. This finding is concerning as it suggests potential nerve or vascular compromise, which could lead to serious complications if not addressed promptly. It is important for the nurse to report this finding to the healthcare provider for further evaluation and intervention.

Correct Answer: B

Rationale: B. Reduce saturated fats in the diet: Consuming high levels of saturated fats can lead to an increase in cholesterol levels, which can contribute to the development of cardiovascular diseases. Therefore, reducing saturated fats in the diet can help maintain a healthy cardiovascular system.

Correct Answer: B

Rationale: In a client with left-sided heart failure, lying on the left side can help reduce the workload on the heart by promoting better venous return and reducing preload. This position can help decrease the amount of blood in the pulmonary circulation and improve cardiac output. Placing one pillow under the head can provide comfort and proper alignment of the airway, allowing for easier breathing. It is important to avoid excessive elevation of the head as it could increase pressure on the heart and impede circulatory function. This position can also help prevent complications such as pulmonary congestion and fluid accumulation in the lungs.

Correct Answer: D

Rationale: Creatinine clearance is a diagnostic test that helps determine both the glomerular filtration rate (GFR) and the extent of glomerular damage in the renal system. Creatinine is a waste product produced by muscles and excreted by the kidneys. A decrease in the glomerular filtration rate indicates impaired kidney function, which could be due to glomerular damage or other renal issues. By measuring the amount of creatinine in the blood and urine over a specific period of time, creatinine clearance provides an estimate of the GFR. This test is commonly used to assess kidney function in patients with renal disease or renal impairment.

Correct Answer: C

Rationale: Progressive shock leads to a mismatch between oxygen demand and supply, causing a shift from aerobic to anaerobic metabolism in cells. As oxygen delivery decreases due to factors such as decreased blood volume or cardiac output, cells are unable to meet their energy needs through aerobic metabolism. This results in the conversion of pyruvate to lactate through anaerobic glycolysis, leading to lactic acidosis and further cellular dysfunction. Recognizing this shift in metabolism is crucial for the nurse to intervene promptly to restore tissue perfusion and prevent further organ damage in the client in hemorrhagic shock.