Nokea
A nurse is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines which of the following percents most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct Answer: C
Rationale: Each lower extremity is scored as 18% according to the Rule of Nines, which estimates burn severity.
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In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms
- B. nutritional status
- C. bleeding problems
- D. availability of insulin
Correct Answer: C
Rationale: Bleeding problems are not typically associated with diabetes management. Assessing diabetic symptoms, nutritional status, and insulin availability are critical to ensure glycemic control in a disaster.
Which cultural group has the highest incidence of inflammatory bowel disease (IBD)?
- A. Asians
- B. Caucasians
- C. Hispanics
- D. African Americans
Correct Answer: B
Rationale: Caucasians have the highest incidence of inflammatory bowel disease (IBD).
A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?
- A. Because it gives you comfort, you may wear it
- B. It is a violation of religious rights to forbid it
- C. I am sorry, but it is not safe for you to wear the crucifix during this test
- D. You may wear it because it is important to you
Correct Answer: C
Rationale: No metal objects, including religious pendants, can be worn during MRI due to safety risks from the strong magnet. Alternative spiritual support should be offered.
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct Answer: C
Rationale: The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash.
When a client has a chest drainage system in place, where should the system be placed?
- A. above the client's head
- B. at the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct Answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest so that the drainage flows out of the chest into the system. The remaining choices are too high and do not allow fluid to drain out of the chest.