Nokea
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
- A. Edema at the site
- B. Severe pain at the site
- C. Epithelialization at the site
- D. Blistering at the site
Correct Answer: A
Rationale: The correct answer is A: Edema at the site. After sustaining major full-thickness burns, the body initiates an inflammatory response, leading to increased capillary permeability and fluid accumulation in the interstitial space, causing edema. This is a normal physiological response to burns. Edema helps in the healing process by providing nutrients and oxygen to the damaged tissues. Choices B, C, and D are incorrect. Severe pain may not be present initially due to nerve damage from the burn. Epithelialization typically occurs during the later stages of burn healing. Blistering is more commonly seen in partial-thickness burns rather than full-thickness burns.
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A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase the amount of fresh fruits and vegetables I consume.'
- B. I will need to take my clothes to the dry cleaners to sterilize them.'
- C. I will be sure to wear gloves and wash my hands when I change my cat's litter box.'
- D. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
- A. You will not be able to eat or drink after the procedure until you are able to cough.
- B. You will need to take deep breaths through your nose during the procedure.
- C. The procedure is painful
- D. and sedation will not be used.
- E. You will need to stay on bed rest for 24 hours after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should include the statement "You will not be able to eat or drink after the procedure until you are able to cough" because it is essential for the client's safety to prevent aspiration. After a bronchoscopy, the client may have an impaired gag reflex from the procedure, increasing the risk of choking. Therefore, it is crucial to wait until the gag reflex returns before eating or drinking. This statement emphasizes the importance of airway protection post-procedure.
Summary:
B: Incorrect - Breathing during a bronchoscopy is usually done through the mouth.
C: Incorrect - Bronchoscopy is uncomfortable but not typically painful due to sedation.
D: Incorrect - Sedation is commonly used during bronchoscopy to ensure client comfort.
E: Incorrect - Bed rest after a bronchoscopy is not typically necessary unless complications arise.
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Administering aspirin is the priority action for a client with acute angina as it helps in reducing platelet aggregation and improving blood flow to the heart. This action can potentially prevent further clot formation and decrease the risk of a heart attack. It is essential to address the acute symptoms first before proceeding with other interventions. Measuring blood pressure (A), administering nitroglycerin (C), and initiating IV access (D) are important actions but administering aspirin takes precedence in this scenario to address the acute angina symptoms promptly.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.