Nokea
The nurse is caring for a client in the emergency department (ED) who sustained a high-voltage (major) electrical burn. Which laboratory data should the nurse monitor to determine if the client is experiencing a complication from this injury?
- A. Creatine phosphokinase (CK)
- B. White blood cells
- C. Serum lipase
- D. Serum glucose
Correct Answer: A
Rationale: High-voltage electrical burns can cause muscle damage, releasing creatine phosphokinase (CK) into the blood, indicating rhabdomyolysis. Monitoring CK levels helps detect complications like renal failure. White blood cells (B), lipase (C), and glucose (D) are less specific for electrical burn complications.
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The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?
- A. Whole grains.
- B. Green leafy vegetables.
- C. Meats and dairy products.
- D. Broccoli and brussels sprouts.
Correct Answer: C
Rationale: Vitamin B12 is primarily found in animal products, such as meats and dairy products, making them the best dietary sources. Whole grains, green leafy vegetables, broccoli, and brussels sprouts contain little to no vitamin B12. Clients with B12 deficiency, such as those with pernicious anemia, should be encouraged to consume meats and dairy to meet their B12 needs.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
Which of the following assessments should be a priority immediately after nasal surgery?
- A. Assessing the client's pain.
- B. Inspecting for periorbital ecchymosis.
- C. Assessing respiratory status.
- D. Measuring intake and output.
Correct Answer: C
Rationale: Respiratory status is the priority post-nasal surgery due to the risk of airway obstruction from packing or swelling. Pain, ecchymosis, and fluid balance are important but secondary to airway patency.
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
- A. 18%.
- B. 27%.
- C. 45%.
- D. 64%.
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.