The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands.
Which finding would the nurse expect to note in this condition?
Red skin with edema in the nail beds.
Black fingertips surrounded by an erythematous rash.
A white appearance to the skin that is insensitive to touch.
A pink edematous hand.
The Correct Answer is C
Choice A rationale
Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.
Choice B rationale
Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.
Choice C rationale
A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.
Choice D rationale
A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.
Choice B rationale
While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.
Choice C rationale
The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.
Choice D rationale
Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.
Correct Answer is ["325"]
Explanation
Step 1 is to determine the total volume of fluid to be infused in the first 8 hours. According to the Parkland formula for fluid resuscitation, half of the prescribed volume is administered in the first 8 hours. Thus:
Total fluid for the first 8 hours = 5,200 mL ÷ 2 = 2,600 mL.
Step 2 is to calculate the infusion rate in mL/hr for the first 8 hours. Divide the total volume for the first 8 hours by the total time in hours:
Infusion rate = 2,600 mL ÷ 8 hr = 325 mL/hr.
Final calculated answer: 325 mL/hr.
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