Nokea
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
- A. Airway obstruction
- B. Paralytic ileus
- C. infection
- D. Fluid imbalance
Correct Answer: A
Rationale: Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and inhalation injury. Ensuring a patent airway is critical for oxygenation and survival, taking precedence over other concerns.
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A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
- A. To place my leg under a heat lamp every 3 hours
- B. Keep a heating pad on the calf of my right leg when I am lying down.
- C. wrap a warm, wet towel around my right calf every 4 hours.
- D. will sit on the side of the tub and soak my right leg two times every day.
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
- A. impaired skin integrity
- B. Alteration in activity tolerance
- C. Impaired tissue perfusion
- D. Alteration in body image
Correct Answer: C
Rationale: Impaired tissue perfusion is the priority because varicose veins, ulcerations, and edema suggest poor blood flow, which can lead to worsening complications. Addressing perfusion improves skin integrity and prevents further deterioration, making it more critical than activity tolerance or body image.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
- A. Hemoglobin level
- B. Fluid intake
- C. Temperature
- D. Skin color
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?
- A. Mood changes
- B. Mobility challenges
- C. Shortness of breath
- D. Sleep disturbance
Correct Answer: A,B,C,D
Rationale: B12 deficiency can cause mood changes (neurological effects), mobility challenges (neuropathy), shortness of breath (anemia), and visual deficits (optic nerve damage). Sleep disturbance is not typical.