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A nurse is caring for a client who has a full-thickness burn. Which of the following actions should the nurse take?
- A. Implement fluid restriction.
- B. Provide humidified oxygen.
- C. Administer antibiotic medications.
- D. Administer acyclovir orally.
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Full-thickness burns can compromise the client's ability to breathe due to airway swelling and damage. Providing humidified oxygen helps support respiratory function by improving oxygenation and reducing the risk of hypoxia. Implementing fluid restriction (A) is not appropriate as burn patients typically require increased fluid intake to prevent dehydration. Administering antibiotic medications (C) may be necessary to prevent infection but is not the priority in this scenario. Administering acyclovir orally (D) is used to treat viral infections, not full-thickness burns.
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A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries.'
- B. I often have diarrhea after eating scrambled eggs.'
- C. I have trouble breathing if I eat acidic foods.'
- D. I sometimes start to wheeze when I eat peanuts.'
Correct Answer: D
Rationale: The correct answer is D because wheezing after consuming peanuts indicates a potential allergic reaction, which could also extend to latex due to cross-reactivity. Peanuts and latex share similar proteins, leading to potential allergic responses. Choices A, B, and C do not indicate a direct correlation to latex allergy and are unrelated symptoms.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Butterfly' rash
- C. Esophagitis
- D. Trophil
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus (SLE) commonly presents with joint inflammation due to inflammation of the synovial membrane. This can lead to pain, swelling, and stiffness in the joints. The other choices are incorrect because: B: Butterfly rash is a characteristic facial rash seen in SLE, but it is not related to joint involvement. C: Esophagitis is inflammation of the esophagus and is not a common manifestation of SLE. D: Trophil is not a recognized term in relation to SLE or its symptoms.
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
- A. Instruct the client to sit on a rubber ring when seated in a chair.
- B. Raise the head of the client's bed to a 90° angle.
- C. Place pillows between the client's knees when in a side-lying position.
- D. Use moisturizing lotion while massaging the client's bony prominences.
Correct Answer: C
Rationale: The correct answer is C: Place pillows between the client's knees when in a side-lying position. Placing pillows between the knees helps maintain proper alignment of the hips and spine, preventing the development of pressure ulcers and improving comfort for the client. Choice A is incorrect as sitting on a rubber ring does not directly address the client's hemiplegia. Choice B is incorrect because raising the head of the bed to a 90° angle may not be suitable for a client with hemiplegia due to potential issues with positioning and pressure distribution. Choice D is incorrect as using moisturizing lotion while massaging bony prominences is not a specific intervention for hemiplegia care.
A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Triiodothyronine
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Triiodothyronine. In Graves' disease, there is overproduction of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are characteristic due to increased thyroid hormone synthesis and release. Triiodothyronine is the active form of thyroid hormone, affecting metabolism, heart rate, and other body functions. Phosphorus (B), calcium (C), and thyroid-stimulating hormone (D) are not typically elevated in Graves' disease. Phosphorus and calcium levels may be normal or even decreased, as the disease primarily affects thyroid hormone levels. Thyroid-stimulating hormone is usually suppressed in Graves' disease due to the negative feedback mechanism of high thyroid hormone levels.