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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A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?
- A. Prep the patient with pain medication.
- B. Notify the patient's family about the procedure via the telephone.
- C. Decrease the temperature of the blood to be given.
- D. Increase the temperature of the blood to be given.
Correct Answer: D
Rationale: Warming the blood will reduce the risk of additional cardiac arrhythmia.
The vast majority of deaths resulting from unintentional poisoning occur in:
- A. infants.
- B. toddlers.
- C. teens.
- D. adults.
Correct Answer: B
Rationale: The vast majority of deaths resulting from unintentional poisoning occur in toddlers.
Regardless of their practice area, nurses should be concerned with:
- A. All drug-resistant bacteria
- B. Microorganisms that are critical
- C. Transmission of microorganisms
- D. Overprescription of bacteriostatic drugs
Correct Answer: C
Rationale: Preventing microorganism transmission is a universal nursing concern to protect clients, families, and staff, achieved through asepsis and infection control practices.
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.
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.