Nokea
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
- A. To prevent the deadly complication of aspiration
- B. To make the client more comfortable
- C. To help prevent paralytic ileus
- D. To help prevent excessive fluid loss
Correct Answer: C
Rationale: Severe burns predispose clients to paralytic ileus due to stress and fluid shifts, so keeping the client NPO prevents complications until bowel function returns.
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Before the examination can be completed, which type of eye medication would the nurse instill in the client's eye to dilate the pupil and temporarily paralyze the ciliary muscle?
- A. Pilocarpine (Pilocar)
- B. Dipivefrin (Propine)
- C. Gentamicin (Genoptic)
- D. Cyclopentolate solution (Cyclogyl)
Correct Answer: D
Rationale: Cyclopentolate is a cycloplegic agent that dilates the pupil and paralyzes the ciliary muscle for retinoscopy.
Which activity should the client who underwent a stapedectomy avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
- A. 36
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
- A. The ear feels less warm to the touch.
- B. Ear drainage is thin and watery.
- C. Ear discomfort is relieved.
Correct Answer: C
Rationale: Relief of ear discomfort indicates the infection is responding to treatment.
The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
- A. Instruct the football players to wear tight, snug-fitting jock straps.
- B. Explain the importance of wearing white socks.
- C. Teach the football players to not share brushes or combs.
- D. Discuss the need to dry the groin area thoroughly after bathing.
Correct Answer: D
Rationale: Thorough drying prevents moisture buildup, reducing tinea cruris risk. Tight jock straps trap moisture, socks are irrelevant, and brushes are unrelated.