Nokea
A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority?
- A. Ineffective airway clearance related to edema
- B. Disturbed body image related to physical appearance
- C. Impaired urinary elimination related to fluid loss
- D. Risk for infection related to epidermal disruption
Correct Answer: A
Rationale: Airway clearance is the top priority in burn patients, especially with facial burns, as swelling can obstruct the airway.
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Which of the following skills would be expected of a 7-month-old infant but not of a 5-month-old infant?
- A. Crawls
- B. Smiles socially
- C. Controls bowel and bladder
- D. Sits unsupported
Correct Answer: D
Rationale: A 7-month-old can typically sit unsupported, while a 5-month-old cannot. Crawling and social smiling develop earlier, and bowel control is not expected at this age.
A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?
- A. Teach the client about the importance of hydration
- B. Report the volume of emesis to the healthcare provider
- C. Administer ondansetron hydrochloride (Zofran)
- D. Encourage the client to limit the amount of movement
Correct Answer: C
Rationale: Administering ondansetron (Zofran) will help relieve the vomiting and prevent dehydration, addressing the immediate concern.
Which among the following is an anatomical scoring system?
- A. STS Score.
- B. Euroscore II
- C. SYNTAX Score
- D. GRACE Score
Correct Answer: C
Rationale: SYNTAX Score is an anatomical scoring system used to assess coronary artery disease.
Manifestations of endocarditis include all of the following EXCEPT
- A. Gottron nodules
- B. hematuria
- C. petechiae
- D. splenomegaly
Correct Answer: A
Rationale: Gottron nodules are associated with dermatomyositis, not endocarditis.
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
- A. I will consult the provider to prescribe a sleep study to determine the problem.
- B. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
- C. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.
- D. Use pillows to elevate your head and chest while you are sleeping.
Correct Answer: D
Rationale: Elevating the head and chest can reduce fluid accumulation in the lungs, improving breathing and sleep quality in clients with advanced cardiac disease.