Nokea
In evaluating the adequacy of fluid resuscitation in a burn client, which assessment provides the most reliable indicator?
- A. Vital signs
- B. Urine output
- C. Mental status
- D. Peripheral pulses
Correct Answer: B
Rationale: Urine output is the most reliable indicator of fluid resuscitation adequacy as it reflects renal perfusion.
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The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?
- A. Use a disposable blood pressure cuff to avoid sharing with other clients.
- B. Change gloves between wound care on different parts of the client's body.
- C. Use the closed method of burn wound management for all wound care.
- D. Advocate for proper and consistent handwashing by all members of the staff.
Correct Answer: B
Rationale: Changing gloves between wound care on different body parts prevents autocontamination.
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale, where the child points to a face, is age-appropriate for a 4-year-old, who may not understand numerical scales or complex words.
Nurse Jeff is performing skin assessment on a client with a facial lesion. It appears as a well-defined, red, scaling, thickened bump. This type of skin lesion refers to?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Melanoma
- D. Actinic keratosis
Correct Answer: B
Rationale: Squamous cell carcinoma often presents as a red, scaling, thickened bump, typically on sun-exposed areas like the face.
Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective?
- A. I should administer the medication in a different nostril each day.'
- B. I need to drink a lot of water when I take my medicine.'
- C. I have to dilute the medication with vitamin D before I take it.'
- D. This medication will help the calcium leave my bones.'
Correct Answer: A
Rationale: Alternating nostrils for calcitonin nasal spray prevents irritation, indicating effective teaching.
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority?
- A. Ensure that the client has been intubated
- B. Set the defibrillator to the 'synchronize' mode
- C. Administer an amiodarone bolus intravenously
- D. Confirm that the rhythm is actually ventricular fibrillation
Correct Answer: D
Rationale: Confirming ventricular fibrillation ensures defibrillation is appropriate; synchronization is for cardioversion, not VF.