Nokea
The nurse determines that the fluid status of the client with a second-degree burn is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse's action?
- A. Blood pressure 92/60 mm Hg and pulse 100 bpm
- B. Respirations 18 per minute and pulse 60 bpm
- C. Pulse 130 bpm and urine output 25 mL/hr
- D. Pulse 106 bpm and temperature 98.4°F (36.9°C)
Correct Answer: C
Rationale: The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132 lb, a pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs of inadequate circulating fluid volume. The MAP for a BP of 92/60 mm Hg is 70.7, indicating adequate perfusion. A pulse of 100 bpm is WNL. Respirations of 18 per minute and pulse of 60 bpm are both WNL. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (36.9°C) is considered normal.
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A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question?
- A. Showering daily with antiseptic soap should be sufficient.
- B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary.
- C. Psoriasis is not contagious, so no special precautions are necessary.
- D. Psoriasis is transmitted primarily by direct contact with the skin.
Correct Answer: C
Rationale: Psoriasis is a non-contagious autoimmune condition, so no precautions are needed to prevent transmission to family members.
The nurse compares the characteristics of open-angle glaucoma with those of angle-closure glaucoma. Which of the following statements describe ways they are similar? Select all that apply.
- A. The visual field examination demonstrates a loss of vision.
- B. Clients are initially treated with medications.
- C. Blurred vision is a common manifestation.
- D. Attacks are self-limited but are more harmful with each episode.
- E. Surgery is often required.
Correct Answer: A,B,E
Rationale: Both types cause vision loss, are initially treated with medications, and may require surgery.
The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.
The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can’t afford to take the medication the physician prescribed. The nurse’s response will be based on which scientific rationale?
- A. The toes will become gangrenous and may have to be amputated.
- B. Over-the-counter antifungal creams can be substituted for the oral medication.
- C. The toenail plate will separate and the entire toenail may be destroyed.
- D. Take all the prescribed antibiotics or the infection may return.
Correct Answer: C
Rationale: Untreated onychomycosis can destroy the toenail plate, causing separation. Gangrene is unlikely, OTC creams are less effective, and antibiotics are irrelevant.
Which questions should the nurse ask to investigate the cause of the client's rash? Select all that apply.
- A. Have you eaten foods that are different from your normal diet?
- B. Have you taken any new medications?
- C. Have you changed your laundry detergent?
- D. Have you been exposed to excessive sunlight?
- E. Have you been exercising in a gym?
- F. Have you gotten any new pets?
Correct Answer: A,B,C,D,F
Rationale: These factors are common triggers for rashes.