Nokea
A young adult client is scheduled for her first debridement of a second-degree burn of the left arm.
It is MOST important for the nurse to take which of the following actions?
- A. Assemble all necessary supplies and medications.
- B. Plan adequate time for the dressing change and provide emotional support.
- C. Prepare the client and family for the pain the client will experience during and after the procedure.
- D. Limit visitation prior to the procedure to reduce stress.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate, but is not a high priority (2) correct-planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure, but on providing the emotional support necessary for the client (3) appropriate, but is not a high priority (4) appropriate, but is not a high priority
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A five-year-old girl after the application of a cast to the left arm.
After the cast is applied, the nurse should
- A. petal the edges of the cast to prevent irritation.
- B. elevate the client's left arm on two pillows.
- C. apply cool, humidified air to dry the cast.
- D. ask the client to move her fingers to maintain mobility.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct-minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take his insulin each day at 1400 hours
- B. Engage in physical activity daily
- C. Increase the amount of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi's effect involves rebound hyperglycemia due to nighttime hypoglycemia. A bedtime snack with protein and carbohydrates prevents hypoglycemia. Options A, B, and C do not directly address this issue.
A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
The nurse is teaching a client with a new diagnosis of glaucoma about timolol (Timoptic) eye drops. Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any shortness of breath.
- C. Use the drops every 4 hours.
- D. Avoid blinking after administration.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bronchospasm; shortness of breath requires reporting. Options A, C, and D are incorrect.