Nokea
A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?
- A. The skin
- B. The intrathoraxic
- C. The muscles supporting the long bones
- D. The bones
Correct Answer: B
Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.
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What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?
- A. Ranitidine 150 mg daily by mouth
- B. Ranitidine 150 mg per os qhs
- C. Ranitidine 150 mg po qd nightly
- D. Ranitidine 150 mg PO at bedtime
Correct Answer: D
Rationale: Ranitidine 150 mg PO at bedtime accurately specifies the dose, route, and timing (qhs = at bedtime). Other options are less precise or redundant (e.g., ‘qd nightly’).
A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: A-C are associated side effects of Tegretol.
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
- A. Gum bleeding
- B. Lung sounds
- C. Homan's sign
- D. Generalized weakness
Correct Answer: A
Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.
The nurse is reviewing the medication profile for a client with chronic obstructive pulmonary disease. Which prescription should the nurse question?
- A. Amlodipine
- B. Codeine
- C. Ipratropium
- D. Methylprednisolone
Correct Answer: B
Rationale: Codeine, an opioid, suppresses cough and respiration, risking respiratory depression in COPD. Amlodipine treats hypertension, ipratropium relieves bronchospasm, and methylprednisolone reduces inflammation, all appropriate for COPD.