Nokea
A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.
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Which breakfast selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. Scrambled eggs, toast, and coffee
- B. Bran muffin with margarine
- C. Granola bar and half of a grapefruit
- D. Bagel with jam and skim milk
Correct Answer: D
Rationale: Skim milk is high in calcium, essential for bone health in osteoporosis. The other options lack significant calcium sources, making them less appropriate.
Which of the following actions does NOT require the use of standard precautions?
- A. contact with blood
- B. contact with urine
- C. contact with sweat
- D. contact with vomit
Correct Answer: C
Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.
The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
- A. A client receiving decadron for emphysema
- B. A client with chest trauma and a new onset of hemoptysis
- C. A client with rib fractures and an O2 saturation of 93%
- D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Correct Answer: B
Rationale: New-onset hemoptysis in a chest trauma client indicates potential serious complications (e.g., pulmonary hemorrhage) requiring RN assessment and intervention.
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
- A. Calcium-rich foods
- B. Canned or frozen vegetables
- C. Processed meat
- D. Raw fruits and vegetables
Correct Answer: D
Rationale: Raw fruits and vegetables may harbor pathogens, increasing infection risk in immunocompromised clients with HIV.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- A. Providing a calm environment
- B. Obtaining a diet history
- C. Administering an analgesic
- D. Assessing fetal heart tones
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.