Nokea
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.
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A client with liver failure and ascites is having a paracentesis to relieve severe dyspnea resulting from abdominal fluid accumulation. Prior to the procedure, the nurse assists the client to urinate. Which of the following is the most important reason to have the patient urinate?
- A. Patient comfort
- B. Prevention of incontinence
- C. Prevention of bladder puncture
- D. Fluid displacement
Correct Answer: C
Rationale: Urinating before paracentesis prevents bladder puncture (C) by emptying the bladder, reducing risk during needle insertion.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.
Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:
- A. The client with ulcerative colitis
- B. The client with neutropenia
- C. The client with cholecystitis
- D. The client with polycythemia vera
Correct Answer: B
Rationale: Neutropenia increases infection risk, so a private room minimizes exposure to pathogens.
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
- A. a client with Alzheimer’s requiring assistance with feeding.
- B. a client with osteoporosis complaining of burning on urination.
- C. a client with scleroderma receiving a tube feeding.
- D. a client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: standard, unchanging procedure