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During a first aid class, the nurse instructs clients on the emergency care of second-degree burns.
- A. Which intervention for second-degree burns of the chest and arms best prevents infection?
- B. Wash the burn with an antiseptic soap and water.
- C. Remove clothing and wrap the victim in a clean sheet.
- D. Leave the blisters intact and apply an ointment.
- E. Take no action until the victim arrives in a burn unit.
Correct Answer: B
Rationale: Removing clothing and wrapping the victim in a clean sheet minimizes contamination and prevents infection in an emergency setting. Soap, ointments, or delaying action increase infection risk by introducing irritants or leaving the wound exposed.
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The nurse is caring for a client with a history of heart failure who is receiving metoprolol (Lopressor) 50 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 50 bpm.
- B. Blood pressure of 130/80 mmHg.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: A heart rate of 50 bpm indicates bradycardia, a serious side effect of metoprolol, a beta-blocker, requiring immediate evaluation to prevent reduced cardiac output. Options B, C, and D are normal: blood pressure 130/80 mmHg, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
A 24-year-old woman who is 30 weeks pregnant is seen in the outpatient clinic for a routine visit.
The nurse would be MOST concerned if the client made which of the following statements?
- A. During the day I seem to get hot flashes and chills.
- B. I am having some trouble with constipation and hemorrhoids.
- C. At the end of the day I have leg cramps.
- D. When I put my hand on my abdomen, I can feel it tense and relax.
Correct Answer: A
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) correct-should be reported to the physician (2) common due to pressure of growing fetus (3) common due to compression of nerves supplying lower extremities or reduced calcium levels, should take oral calcium supplements if ordered, stretch until spasm is relieved (4) Braxton-Hicks contractions common, should rest and change position
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropesol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
- A. Raise the side rails on the bed
- B. Place the call bell within reach
- C. Instruct the client to remain in bed
- D. Have the client empty bladder
Correct Answer: D
Rationale: Have the client empty bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.