Nokea
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
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The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?
- A. Total hip replacement.
- B. Mitral valve repair.
- C. Abdominal hysterectomy.
- D. Mastectomy of the left breast.
Correct Answer: C
Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A. A developing infection.
- B. Bleeding in the operative site.
- C. Joint dislocation.
- D. Glue seepage into soft tissue.
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken?
- A. At bedtime.
- B. All at one time.
- C. Two hours before mealtime.
- D. At the time scheduled.
Correct Answer: D
Rationale: Adhering to the scheduled times ensures consistent drug levels, critical for managing Parkinson's symptoms. Bedtime, single dosing, or pre-meal timing may disrupt therapeutic efficacy.