Nokea
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
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The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
- A. Pinkish red.
- B. Dark yellow-orange.
- C. Clear.
- D. Green.
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
A 27-year-old female is admitted for elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Complaints of nausea.
- B. Repeated swallowing.
- C. Rapid respiratory rate.
- D. Feelings of anxiety.
Correct Answer: B
Rationale: Repeated swallowing may indicate postnasal bleeding, as blood may flow down the throat rather than out the nose, even if the nasal drip pad remains dry.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following?
- A. Signs of skin pressure in the groin area.
- B. Evidence of decreased breath sounds.
- C. Skin breakdown behind the heel.
- D. Urine retention.
Correct Answer: A
Rationale: The Thomas splint can cause pressure in the groin, requiring regular skin assessments to prevent breakdown.