Nokea
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
- A. Implementing relaxation exercises.
- B. Administering a sedative as needed.
- C. Administering prophylactic antacids or histamine-2 receptor antagonists.
- D. Monitoring the client's nutritional status closely.
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
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Mebendazole (Vermox) is prescribed for an 8-year-old child with pinworms. The child has an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also treating which of the following family members with this drug?
- A. Both of the child's siblings
- B. The child's parents and brother
- C. Everyone who lives in the household
- D. The parents and sister
Correct Answer: C
Rationale: Pinworms are highly contagious, so all household members should be treated with mebendazole to prevent reinfection, regardless of symptoms.
What type of immunity occurs when a person has an infectious, communicable disease like the measles?
- A. Adaptive immunity
- B. Passive natural immunity
- C. Active natural immunity
- D. Active artificial immunity
Correct Answer: C
Rationale: Active natural immunity occurs when a person develops immunity after exposure to an infectious disease like measles, producing antibodies through natural infection.
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
- A. At bedtime with a snack.
- B. First thing in the morning with water.
- C. With meals to enhance absorption.
- D. With milk to reduce stomach irritation.
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
- A. Sterile items ONLY are placed on the sterile field.
- B. The nurse must keep the sterile field below waist level.
- C. Coughing or sneezing over the sterile field contaminates the sterile field.
- D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
- E. Moisture and wetness contaminate the sterile field.
- F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
Which of the following is a commonality that is shared in terms of both restraints and urinary catheters?
- A. Both can lead to infection.
- B. Both are invasive procedures.
- C. Both are considered sentinel.
- D. Both are the last resort.
Correct Answer: A
Rationale: Both restraints and urinary catheters can lead to infections restraints through skin breakdown and catheters through urinary tract infections if not managed properly.