Nokea
A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient's laboratory values should the nurse review?
- A. Blood pH level
- B. Hematocrit
- C. White blood cell (WBC) count
- D. Platelet count
Correct Answer: C
Rationale: WBC count indicates infection, relevant to purulent drainage in a burn wound.
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The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient's return demonstration, the patient exhales using pursed lips. What should the nurse do next?
- A. Advise the patient that the procedure is being performed correctly.
- B. Tell the patient to take several shallow breaths before the next exhalation.
- C. Instruct the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times.
- D. Position the patient in the semi-Fowler's position and apply oxygen.
Correct Answer: C
Rationale: Instructing the patient to inhale deeply and exhale forcefully corrects the improper pursed-lip technique, ensuring effective huff coughing to clear mucus.
While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?
- A. Profuse sweating.
- B. Weakness in the lower legs.
- C. Loss of sensation at T-8.
- D. Leg pain that worsens at night.
Correct Answer: C
Rationale: Loss of sensation at T-8 indicates potential progression of Guillain-Barre syndrome, risking paralysis, and requires immediate intervention.
A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.
The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan?
- A. The patient should eat a diet high in protein and vitamins A and C.
- B. The patient should keep their legs elevated when sitting or lying down.
- C. The patient should maintain as much bed rest as possible.
- D. The patient should inspect their ankles daily for areas of darkening skin.
- E. The patient should apply intermittent cold compresses four times daily.
Correct Answer: A,B,D
Rationale: A diet high in protein and vitamins A and C, leg elevation, and daily ankle inspections support healing and early detection of complications in venous leg ulcers.
After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?
- A. Eliminate all spicy foods from your diet
- B. Drink 3 liters of water each day
- C. Clamp the catheter when taking a shower
- D. Avoid driving a car for 2 weeks
Correct Answer: B
Rationale: Adequate hydration (3 liters daily) prevents urinary tract infections and supports recovery after TURP.