PN Adult Medical Surgical 2023 | Nurselytic

Correct Answer: A, D

Rationale: Compartment syndrome requires relieving pressure to restore perfusion. Opening the splint (or cast) reduces external compression, an anticipated step pre-fasciotomy if tightness contributes to ischemia, per orthopedic protocols. Urinalysis checks for myoglobinuria from muscle breakdown, a diagnostic aid, but not immediate relief. NPO status prepares for surgery, a later consideration after pressure relief. A dependent leg position increases venous pooling, worsening swelling and pressure contraindicated here. Opening the splint directly addresses the mechanical cause, buying time for surgical evaluation, aligning with emergency management (e.g., AAOS guidelines), making it the expected prescription to prioritize limb viability.

Correct Answer: C

Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.

Correct Answer: B

Rationale: Post-fasciotomy, pain from surgical incision and prior compartment pressure is expected, making analgesia a priority to enhance comfort and mobility, aiding recovery. Antibiotics are proactive for infection, but no fever or purulent drainage (Exhibit) justifies immediate use prophylaxis may apply, not routine post-op. Fluid restriction contradicts hydration needs for healing and circulation, especially with serosanguinous drainage. Wound cultures are indicated for infection signs (e.g., redness, pus), not routine here with a dry, intact dressing. Pain management aligns with postoperative care principles unrelieved pain increases stress, delays ambulation, and risks chronicity making analgesic administration the most immediate, evidence-based action to support the client's well-being and surgical outcome.

Correct Answer: D

Rationale: Perimenopause brings hormonal shifts, but urinary frequency stands out it may signal a UTI, bladder issue, or pelvic pathology, requiring urgent evaluation over typical symptoms. Difficulty sleeping and hot flashes stem from estrogen fluctuations, common and manageable with lifestyle changes. Vaginal dryness, also hormonal, responds to lubricants or estrogen therapy, not immediate concern. Frequency, however, risks infection or renal complications older women often present atypically (e.g., confusion), per geriatric guidelines. Using ABCs, elimination issues outrank comfort, driving prompt reporting for diagnostics (e.g., urinalysis), preventing progression, making it the priority finding.

Correct Answer: A

Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CD
C). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.