Nokea
The nurse is caring for a client 7 days post-burn injury with 60% body surface area involved. The nursing care of this client would primarily focus on:
- A. Meticulous infection-control measures
- B. Fluid-replacement evaluation
- C. Psychological adjustment to the wound
- D. Measurement and application of a pressure garment
Correct Answer: A
Rationale: At 7 days post-burn, infection is a major risk due to open wounds and immunosuppression, making meticulous infection control the primary focus.
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The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
- A. privacy
- B. Patient's Bill of Rights
- C. continuity of care
- D. case management
Correct Answer: C
Rationale: Proper handoffs ensure continuity of care by transferring critical information accurately between care teams.
Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:
- A. Uterine atony
- B. Retained placental fragments
- C. Cervical laceration
- D. Perineal tears
Correct Answer: B
Rationale: Retained placental fragments are the most common cause of late postpartum hemorrhage, as they prevent proper uterine contraction and hemostasis.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for:
- A. Supplemental oxygen
- B. Fluid restriction
- C. Blood transfusion
- D. Delivery by Caesarean section
Correct Answer: A
Rationale: Sickle cell anemia increases oxygen demand during labor, often requiring supplemental oxygen.
A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, 'How much longer will it be?' Which response by the nurse is most appropriate?
- A. This must be a terrible situation for you.
- B. I don't know. I'll call the doctor.
- C. I cannot say exactly. What are your concerns at this time?
- D. Don't worry, it will be very soon.
Correct Answer: C
Rationale: This response acknowledges the family's concern, provides an honest answer, and opens the conversation to address their specific worries, promoting therapeutic communication.