Nokea
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
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A client has fludrocortisone acetate (Florinef) prescribed. What blood tests should the nurse monitor when administering this drug?
- A. Liver function tests
- B. Renal function tests
- C. Serum electrolytes
- D. Complete blood count
Correct Answer: C
Rationale: Fludrocortisone, a mineralocorticoid, affects sodium and potassium balance, requiring monitoring of serum electrolytes to detect imbalances like hypernatremia or hypokalemia.
A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?
- A. Bradycardia.
- B. Tachypnea.
- C. General pallor.
- D. Irritability.
Correct Answer: B
Rationale: increase in the respiratory rate is an early sign of hypoxia, also for tachycardia
During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
- A. The woman removes her dentures and gives them to her husband.
- B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
- C. The woman has a nitroglycerine patch on her right chest area.
- D. The woman has red nail polish on her fingers and toes.
Correct Answer: C
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following actions is the PRIORITY?
- A. Monitor the client for neck swelling.
- B. Administer pain medication as needed.
- C. Encourage the client to cough and deep breathe.
- D. Check the incision for drainage.
Correct Answer: A
Rationale: Monitoring for neck swelling is the priority to detect hematoma, a life-threatening complication post-thyroidectomy that can cause airway obstruction. Options B, C, and D are important but secondary: pain management, respiratory exercises, and incision checks follow airway safety.