Nokea
A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?
- A. Furosemide (Lasix) IV push
- B. Irrigate the Foley catheter
- C. Increase the IV fluids to 200 mL/hr
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Signs of fluid overload (JVD, edema, low urine output, crackles) suggest the need for furosemide (Lasix) to reduce excess fluid and prevent pulmonary edema.
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The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?
- A. Altered level of consciousness is a late sign of increased ICP.'
- B. Elevated temperature is the earliest indication of increased ICP.'
- C. Late signs of increased ICP include narrowed pulse pressure and a lowered heart rate.'
- D. Late signs of increased ICP include increased systolic blood pressure and a widened pulse pressure.'
Correct Answer: D
Rationale: Late ICP signs include Cushing’s triad: increased systolic BP, widened pulse pressure, and bradycardia, reflecting brainstem compression.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
A neonatal nurse assesses a premature newborn baby using the Apgar score. All of the following assessments are given a score EXCEPT
- A. grimace.
- B. pulse.
- C. activity.
- D. rooting.
- E. appearance.
Correct Answer: D
Rationale: The Apgar score evaluates appearance, pulse, grimace, activity, and respiration. Rooting (a feeding reflex) is not part of the Apgar assessment.
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
- A. Preventing addiction
- B. Alleviating pain
- C. Facilitating mobility
- D. Preventing nausea
Correct Answer: B
Rationale: The primary goal of opiate analgesics like Percocet is to alleviate pain, improving comfort and recovery post-surgery.
Along with traditional therapy, a client asks the nurse about alternative therapies for chronic pain. Which could the nurse provide to the client?
- A. yoga
- B. acupuncture
- C. music therapy
- D. hypnosis
Correct Answer: A, B, C, D
Rationale: Yoga, acupuncture, music therapy, and hypnosis are all recognized alternative therapies for managing chronic pain, complementing traditional treatments.