Nokea
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
- A. Replace fluids and electrolytes.
- B. Prevent contractures of extremities.
- C. Monitor urine output hourly.
- D. Prepare to assist with an escharotomy.
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.
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Which symptom related to the chronic progression of untreated glaucoma will a client most likely report to the nurse?
- A. Tunnel vision
- B. Double vision
- C. Bulging eyes
- D. Bloodshot eyes
Correct Answer: A
Rationale: Untreated glaucoma leads to tunnel vision due to progressive peripheral vision loss.
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
If a client who has recently experienced diminished hearing takes medications from each of the following drug categories, which one is most likely to have affected the client's hearing?
- A. Nonsteroidal anti-inflammatory drug
- B. Beta-adrenergic blocker
- C. Aminoglycoside antibiotic
- D. Histamine-2 (H2) antagonist
Correct Answer: C
Rationale: Aminoglycosides are ototoxic and can cause hearing loss.
The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide?
- A. Notify the HCP if a nonhealing lesion develops around the mouth.
- B. Squamous cell carcinoma tumors do not metastasize.
- C. Limit foods to liquid or soft consistency for one (1) month.
- D. Apply heat to the area for 20 minutes every four (4) hours.
Correct Answer: A
Rationale: Nonhealing lesions suggest recurrence, requiring HCP notification. Squamous cell carcinoma can metastasize, diet restrictions are unnecessary, and heat is inappropriate.
The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, 'How can I prevent getting impetigo?' Which statement would be the most appropriate response?
- A. Wash your hands after using the bathroom.'
- B. Do not touch any affected areas without gloves.'
- C. Apply a topical antibiotic to your hands.'
- D. Keep the child with impetigo isolated in the room.'
Correct Answer: B
Rationale: Avoiding contact with impetigo lesions without gloves prevents transmission. Handwashing is general, topical antibiotics are for treatment, and isolation is excessive.