Nokea
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
You may also like to solve these questions
The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. “It will raise you BP, which is necessary because of blood loss.”
- B. “It will dilate your bronchioles and make your breathing easier.”
- C. “It will help your blood to clot to reduce bleeding.”
- D. “It will constrict your vessels and slow down the bleeding.”
Correct Answer: D
Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.
Which of the ff dietary recommendations should a nurse give to a client taking diuretics?
- A. Include potassium rich foods
- B. Avoid fruit and fruit juices
- C. Include protein rich foods
- D. Avoid dairy products
Correct Answer: A
Rationale: The correct answer is A: Include potassium-rich foods. Diuretics can cause potassium loss, leading to hypokalemia. Including potassium-rich foods helps prevent this deficiency. Choice B is incorrect because fruits and fruit juices are often good sources of potassium. Choice C is incorrect as protein-rich foods do not specifically address potassium needs. Choice D is incorrect as dairy products are also good sources of potassium. Therefore, recommending potassium-rich foods is essential to prevent hypokalemia in clients taking diuretics.
A client has type1 diabetes. Her husband finds her unconscious at home and administers glucagons, 0.5 mg S.C. She awakens in 5 minutes .Why her husband offer a complex carbohydrate snack to her as soon as possible?
- A. To decrease the possibility of nausea and vomiting
- B. To restore liver glycogen and prevent secondary hypoglycemia
- C. To stimulate her appetite
- D. To decrease the amount of glycogen in her system
Correct Answer: B
Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections.
- Choice B: Cognitive problems, is not directly related to lymphocyte levels.
- Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes.
- Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.
The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: C
Rationale: The correct answer is C: Psychomotor. The nurse is demonstrating psychomotor skills by inserting an IV catheter correctly. Psychomotor skills involve the ability to perform physical tasks effectively and efficiently. This skill requires coordination, dexterity, and precision. The other choices are incorrect because:
A: Cognitive skills involve thinking, analyzing, and problem-solving.
B: Interpersonal skills involve communication and interaction with others.
D: Judgmental skills involve critical thinking and decision-making.