Nokea
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.
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The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
- A. Maintain the client in a supine position.
- B. Maintain a high-Fowler’s position when the client is in bed.
- C. Elevate the stump on a pillow.
- D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Correct Answer: D
Rationale: Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
- A. Fat neck veins.
- B. Hypotension.
- C. Poor skin turgor.
- D. Bradycardia.
- E. Pale yellow urine.
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration. Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
- A. Remove the vest daily to inspect the client’s skin integrity.
- B. Check that the halo jacket is snug against the client’s skin.
- C. Provide range of motion to the client’s neck.
- D. Monitor the client for an elevated temperature.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (Choice A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (Choice B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (Choice C) is contraindicated with a halo device as it can cause serious injury.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.
A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?
- A. Silvery, white scales.
- B. Intense pain.
- C. Unilateral lesions.
- D. Serous drainage.
Correct Answer: A
Rationale: The correct answer is A: Silvery, white scales. Psoriasis is characterized by the presence of silvery, white scales on the skin due to rapid skin cell turnover. This finding is classic for psoriasis. Intense pain (B) is not a typical symptom of psoriasis; it is more commonly associated with conditions like shingles. Unilateral lesions (C) would not be expected in psoriasis, as it often affects both sides of the body symmetrically. Serous drainage (D) is not a typical feature of psoriasis, which primarily presents with dry, scaly patches.