Nokea
The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
- A. Body image disturbance
- B. Risk for infection
- C. Sensory perceptual alterations
- D. Activity intolerance
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.
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The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the pleural space, reducing the risk of pneumothorax.
The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is given annually in:
- A. November
- B. December
- C. January
- D. February
Correct Answer: A
Rationale: Influenza vaccines are typically administered in November, before the peak flu season, to ensure immunity during winter months.
A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:
- A. Tilt the head back and pinch the nostrils
- B. Apply a wrapped ice compress to the nose
- C. Pack the nose with soft, clean tissue
- D. Tilt the head forward and pinch the nostrils
Correct Answer: D
Rationale: Tilting the head forward and pinching the nostrils prevents blood from entering the airway and controls bleeding.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
Which task should be assigned to the nursing assistant?
- A. Placing the client in seclusion
- B. Emptying the Foley catheter of the preeclamptic client
- C. Feeding the client with dementia
- D. Ambulating the client with a fractured hip
Correct Answer: C
Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.