Nokea
A family member of a client who has sustained an electrical burn states, 'I don't understand why he has been here a week. The burn does not look that bad.' Which of the following responses by the nurse is BEST?
- A. Electrical burns are more prone to infection.
- B. Electrical burns are always much worse than they look on the outside.
- C. Cardiac monitoring is important because electrical burns affect cardiac function.
- D. Electrical burns can be deceptive because underlying tissue is also damaged.
Correct Answer: D
Rationale: electrical burn injuries are typically more injurious to underlying tissue such as nerve and vascular tissue, which require complex and timely treatment
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A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
- A. Did you have anything to eat or drink before you came in today?
- B. Have you had any headaches since your last treatment?
- C. Who came with you to the hospital today?
- D. Have you had much memory loss since you began your treatments?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
A client has an order for a low-sodium, low-cholesterol diet. The nurse knows that which of the following selections reflects the client's compliance?
- A. Canned vegetable soup, applesauce, and hot chocolate.
- B. Cheeseburger, french fries, and skim milk.
- C. Tomato and lettuce salad, roasted chicken, and lemonade.
- D. Tuna fish sandwich, cottage cheese, and a cola.
Correct Answer: C
Rationale: fresh fruits and vegetables are low sodium, roasted chicken is low cholesterol
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele