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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 client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
- A. Encourage frequent visits from friends.
- B. Apply restraints to the upper extremities.
- C. Play soft, soothing music.
- D. Keep the over-the-bed light on.
Correct Answer: C
Rationale: The correct answer is C: Play soft, soothing music. This is beneficial for the older adult with dementia post-surgery as music has been shown to reduce anxiety, improve mood, and promote relaxation. It can also help in reducing agitation and promoting better sleep. Encouraging frequent visits from friends (A) may overwhelm the client. Applying restraints to the upper extremities (B) can lead to increased agitation and discomfort. Keeping the over-the-bed light on (D) may disrupt sleep patterns and worsen confusion.
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 assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 13 mm at the injection site. Which of the following instructions should the nurse provide to the client?
- A. You will need to have the skin test annually.
- B. You will need to return in 48 hours for re-evaluation.
- C. Your test will need to be repeated at this time.
- D. You will need to follow up with your provider.
Correct Answer: D
Rationale: The correct answer is D: "You will need to follow up with your provider." The nurse should instruct the client to follow up with their provider because an induration of 13 mm at 48 hours post-PPD indicates a positive result for tuberculosis exposure. Follow-up is necessary to determine if treatment or further evaluation is needed. Choice A is incorrect because annual skin tests are not necessary unless there is ongoing exposure or risk factors. Choice B is incorrect as the client does not need to return in 48 hours for re-evaluation since the test has already been read at 48 hours. Choice C is incorrect as repeating the test is not necessary when a positive result is already present.