Nokea
Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.
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Which statement by the nurse most accurately explains the pathophysiology of conductive hearing loss?
- A. Sound waves do not travel to the inner ear.
- B. There is a malfunction of inner ear structures.
- C. The auditory nerve does not transmit sound to the brain.
Correct Answer: A
Rationale: Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear.
Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing?
- A. Cellulitis.
- B. Lyme disease.
- C. Impetigo.
- D. Deep vein thrombosis.
Correct Answer: A
Rationale: Redness, edema, heat, and streaks post-puncture suggest cellulitis, a bacterial infection. Lyme disease has a bullseye rash, impetigo is superficial, and DVT lacks skin changes.
Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
Which nursing intervention is most appropriate to add to the care plan to reduce the client's anxiety?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.