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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 IV with a large-bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start IV with a large-bore needle. This is the priority intervention because fluid resuscitation is crucial in managing burn injuries to prevent hypovolemic shock. Starting an IV line allows for prompt administration of fluids and medications. Administering analgesic medication (A) can wait until after fluid resuscitation. Increasing room temperature (B) is not a priority in burn management. Cleansing wounds (C) can be done after fluid resuscitation. Starting the IV line with a large-bore needle (D) takes precedence over other interventions to stabilize the client's condition.
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A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day
- B. Avoid extremely hot or cold temperatures
- C. Avoid getting a flu vaccination
- D. Limit alcohol intake to one drink per day
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is important for a client recovering from a sickle cell crisis because extreme temperatures can trigger vaso-occlusive episodes. Sickle cell disease causes red blood cells to become rigid and sticky, leading to blockages in blood vessels, which can be exacerbated by temperature extremes. Limiting exposure to extreme temperatures can help reduce the risk of complications.
A: Limiting fluids is not the priority in this situation. Adequate hydration is important to prevent dehydration and maintain blood flow.
C: Getting a flu vaccination is actually recommended for clients with sickle cell disease, as they are at higher risk of complications from the flu.
D: Limiting alcohol intake is generally advisable, but it is not the most crucial instruction for someone recovering from a sickle cell crisis.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins.
- B. Increased blood pressure.
- C. Decreased blood pressure.
- D. Pitting, dependent edema.
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration leads to a decrease in blood volume, causing a drop in blood pressure. As a result, the body tries to conserve fluids, leading to decreased urine output and concentrated urine. Distended jugular veins (A) are more indicative of heart failure. Increased blood pressure (B) is not typically associated with dehydration. Pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (C) is not directly related to ibuprofen use. Urine for white blood cells (D) is not relevant in this scenario.
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
- A. Obtain the client's vital signs.
- B. Perform a neurologic check.
- C. Turn the client on their side.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: The correct answer is C: Turn the client on their side. This is the first action the nurse should take during a seizure to prevent aspiration and maintain an open airway. Turning the client on their side helps to prevent choking and allows any fluids to drain out of the mouth. Obtaining vital signs (A) and performing a neurologic check (B) can be done after ensuring the client's safety. Notifying the rapid response team (D) is important in some situations, but the immediate priority is to protect the client from harm during the seizure.