Nokea
A client with a history of burns is admitted with a 40% total body surface area injury. The nurse should prioritize which of the following interventions?
- A. Initiate fluid resuscitation.
- B. Administer prophylactic antibiotics.
- C. Apply ice to the burns.
- D. Cover the burns with dry gauze.
Correct Answer: A
Rationale: Fluid resuscitation is the priority to prevent hypovolemic shock in extensive burns.
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A client with type 2 diabetes is prescribed metformin. Which laboratory value should the nurse monitor?
- A. Serum creatinine.
- B. Hemoglobin A1c.
- C. Platelet count.
- D. Serum sodium.
Correct Answer: A
Rationale: Metformin can affect renal function, so monitoring serum creatinine is essential to assess kidney function.
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
Which of the following laboratory tests should the nurse monitor when the client is receiving warfarin sodium (Coumadin) therapy?
- A. Partial thromboplastin time (PTT).
- B. Serum potassium.
- C. Arterial blood gas (ABG) values.
- D. Prothrombin time (PT).
Correct Answer: D
Rationale: Warfarin therapy requires monitoring prothrombin time (PT) to assess anticoagulation effectiveness.
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.
The nurse is caring for a client with a history of liver cirrhosis who is prescribed lactulose (Cephulac). The nurse should expect the client to experience which of the following effects?
- A. Reduced ascites.
- B. Decreased ammonia levels.
- C. Increased appetite.
- D. Weight loss.
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, preventing hepatic encephalopathy.