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A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
- A. 18%.
- B. 27%.
- C. 45%.
- D. 64%.
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
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Which medication is prescribed to prevent uric acid stones?
- A. Hydrochlorothiazide.
- B. Allopurinol.
- C. Potassium citrate.
- D. Acetaminophen.
Correct Answer: B
Rationale: Allopurinol reduces uric acid levels, preventing stone formation.
The nurse is reviewing a client's preoperative checklist and notes the client has not voided in the last 6 hours. The nurse should:
- A. Insert a urinary catheter.
- B. Encourage the client to void before transport.
- C. Notify the anesthesiologist.
- D. Document the finding and proceed.
Correct Answer: B
Rationale: Encouraging the client to void prevents bladder distention during surgery and reduces the need for catheterization, which carries infection risks.
The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
- A. Ate a gelatin dessert at 3:30 a.m.
- B. Brushed his teeth at 4:00 a.m. but did not swallow.
- C. Held a cold washcloth against his lips.
- D. Smoked a cigarette at 6:00 a.m.
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line?
- A. Use a clean technique for all dressing changes.
- B. Tape all connections of the system.
- C. Encourage bed rest.
- D. Cover the insertion site with a moisture-proof dressing.
Correct Answer: B,D
Rationale: To prevent complications with TPN via a central line, taping all connections (B) prevents dislodgement, and a moisture-proof dressing (D) reduces infection risk. Clean technique (A) is insufficient; sterile technique is required. Bed rest (C) is not necessary and may increase complications like thrombosis. CN: Pharmacological and parenteral therapies; CL: Create