Nokea
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start an IV with a large bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start an IV with a large bore needle. This intervention is crucial for fluid resuscitation in burn victims to prevent hypovolemic shock. Starting an IV allows for prompt administration of fluids and medications. Administering analgesics (A) can wait until after fluids are started. Increasing room temperature (B) is not a priority. Cleansing wounds (C) can be delayed until the patient is stabilized. Starting an IV is more urgent than other interventions in the initial management of burn injuries.
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A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: C
Rationale: The correct answer is C: Confusion. In left-sided heart failure, decreased cardiac output can lead to decreased perfusion to the brain, resulting in confusion. Weight gain (A) is more indicative of fluid retention, distended abdomen (B) is a sign of ascites or abdominal organ enlargement, and dyspnea (D) is a common symptom of heart failure but not a direct indicator of decreased cardiac output.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.'
- B. I should take an antacid with each dose of this medication.'
- C. This medication may cause my blood pressure to increase.'
- D. I will have my liver function tested while I am taking this medication.'
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This answer demonstrates understanding because isoniazid (INH) is known to potentially cause liver toxicity. Regular monitoring of liver function is essential to detect any adverse effects early. Option A is incorrect as INH treatment typically lasts for several months, not just 1 week. Option B is incorrect as antacids can decrease the absorption of INH. Option C is incorrect as INH does not typically cause an increase in blood pressure.
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 on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
- A. Propranolol
- B. Dobutamine
- C. Mannitol
- D. Chlorpromazine
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce cerebral edema by drawing water out of brain tissue. This helps decrease intracranial pressure in clients with head injuries. Propranolol (A) is a beta-blocker used for hypertension, not specifically for intracranial pressure. Dobutamine (B) is a beta-adrenergic agonist used for cardiac support, not for intracranial pressure. Chlorpromazine (D) is an antipsychotic medication and does not address intracranial pressure. In summary, Mannitol is the appropriate choice for managing increased intracranial pressure due to its osmotic diuretic properties.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
- A. Palpable thrill
- B. Memorantake blood pressure
- C. Absence of a bruit
- D. Dilated appearance of the graft
Correct Answer: A
Rationale: The correct answer is A: Palpable thrill. A palpable thrill indicates that there is adequate circulation of the arteriovenous graft. A thrill is a vibration felt over the graft site, which suggests that blood is flowing through the graft properly. A palpable thrill is a positive sign of good circulation.
The other choices are incorrect because:
B: Membranous blood pressure does not provide information about the circulation of the graft.
C: Absence of a bruit could indicate decreased or absent blood flow through the graft.
D: Dilated appearance of the graft does not necessarily indicate adequate circulation; it could be due to other reasons such as infection or inflammation.