Nokea
A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the following should be the priority at this time?
- A. Preventing wound infection.
- B. Evaluating vital signs frequently.
- C. Maintaining fluid and electrolyte balance.
- D. Managing the child's pain.
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the priority in burn care to prevent hypovolemic shock due to significant fluid loss.
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The parents of a child with mumps express concern that their child will develop orchitis as a result of having mumps. What characteristic of this complication should the nurse discuss with the parents?
- A. Fever
- B. Facial swelling
- C. Swollen glands
- D. Difficulty urinating
Correct Answer: A
Rationale: Unilateral orchitis occurs more frequently than bilateral orchitis. About 1 week after the appearance of parotitis, there is an abrupt onset of testicular pain, tenderness, fever, chills, headache, and vomiting. The affected testicle becomes red, swollen, and tender. Atrophy, resulting in sterility, occurs only in a small number of cases. Facial swelling and swollen glands normally occur in mumps. Difficulty urinating is not a sign of this complication.
A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Hydrochlorothiazide, a thiazide diuretic, can cause hypokalemia due to potassium loss.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
The clinic nurse provides home care instructions to an adult client diagnosed with influenza. Which instructions should the nurse provide to the client? Select all that apply.
- A. Practice frequent hand washing.
- B. Remain at home until feeling better.
- C. Sneeze or cough into the upper sleeve.
- D. Return in 1 week for an influenza vaccine.
- E. Take acetaminophen for myalgia.
- F. Completely isolate self in a room from other family members and use a separate bathroom until feeling better.
Correct Answer: A,B,C,E
Rationale: Influenza (commonly known as the flu) refers to an acute viral infection of the respiratory tract. It is a communicable disease spread by droplet infection, and measures are instituted to prevent its spread. The client is instructed to practice frequent hand washing, remain at home, and cover the nose and mouth when sneezing and coughing. Supportive measures to relieve fever and myalgia such as the use of acetaminophen are also encouraged. It is unrealistic to completely isolate oneself in a room from other family members, and there is no useful reason to use a separate bathroom because the infection is spread through droplets. Influenza immunization is administered before the start of the 'flu' season, not after developing the infection.