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Extract:

B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.


Question 1 of 5

Potential complication that can be possibly developed will be:

Correct Answer: A

Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.

Extract:

Loss of peripheral vascular resistance:


Question 2 of 5

Loss of peripheral vascular resistance:

Correct Answer: A

Rationale: Loss of peripheral vascular resistance leads to hypotension due to vasodilation.

Extract:


Question 3 of 5

A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)

Correct Answer: A,B,D,E

Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.

Question 4 of 5

The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?

Correct Answer: B

Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°
C) also are common at 24 hours postpartum.

Extract:

A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.


Question 5 of 5

When obtaining information from the patient, the nurse would expect her to report that:

Correct Answer: D

Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.

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