Nokea
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
- A. cover the areas with dry sterile dressings
- B. assess for dyspnea or stridor
- C. initiate intravenous therapy
- D. administer pain medication
Correct Answer: B
Rationale: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
You may also like to solve these questions
The charge nurse is planning hospital bed placements for the five male clients identified in the exhibit. Two double rooms and one private room are available. Which room assignments should be made by the charge nurse?
- A. Client B: private room; clients C and E in same room; clients A and D in same room
- B. Client C: private room; clients A and D in same room; clients B and E in same room
- C. Client E: private room; clients B and C in same room; clients A and D in same room
- D. Client C: private room; clients A and B in same room; clients D and E in same room
Correct Answer: B
Rationale: B: Client C requires airborne precautions and a private room. A and D share the same organism and contact precautions. B and E require standard precautions and can share a room.
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: Lower the oxygen rate. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. Unless corrected, it can lead to the client's death.
The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
- A. Avoid chocolate and cheese
- B. Take frequent naps
- C. Take the medication with milk
- D. Avoid walking without assistance
Correct Answer: A
Rationale: Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine, and cheese may precipitate hypertensive crisis.
During a health promotion seminar, the nurse plans to discuss ways to prevent food poisoning. What information should the nurse plan to address?
- A. Keep all meat together during the preparation, cooking, and serving processes.
- B. Drink natural unpasteurized milk because it contains less harmful chemicals.
- C. Wash fruits and vegetables thoroughly, especially those that will be eaten raw.
- D. Ensure that ground beef patties are cooked to a temperature of 125°F (51.7°C).
Correct Answer: C
Rationale: C: Thorough washing of raw produce removes bacteria, preventing food poisoning. A: Meats should be separated to avoid cross-contamination. B: Unpasteurized milk carries infection risks. D: Ground beef must reach 160°F to kill pathogens.
The client with an infected leg wound receives treatment and a prescription for antibiotics during a clinic visit. Which information should the nurse emphasize when completing discharge teaching?
- A. Return to the clinic in one week for a repeat tetanus injection.
- B. Avoid disturbing the dressing until next week's visit with the provider.
- C. If you have chills and your temperature is over 101°F (38.3°C), call the HCP.
- D. Do not take cold medicines for 24 hours after starting the antibiotic.
Correct Answer: C
Rationale: C: Chills and fever over 101°F indicate possible antibiotic failure, requiring prompt reporting. A: Tetanus shots are not repeated weekly. B: Dressings need frequent changes for infected wounds. D: Cold medicines are generally safe unless contraindicated.