Nokea
The nurse is caring for a client who was admitted to the burn unit 4 hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hypernatremia is least expected within 4 hours of a burn injury, as fluid shifts typically cause hyponatremia due to third-spacing. Hypovolemia, laryngeal edema, and hyperkalemia are common early findings.
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A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.
A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:
- A. Performing an assessment
- B. Obtaining a blood permit
- C. Initiating an IV with a large-bore needle
- D. Inserting an NG tube
Correct Answer: C
Rationale: Severe hematemesis indicates significant bleeding, requiring immediate IV access with a large-bore needle for fluid and blood resuscitation to stabilize the client.
A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
The nurse is teaching a client with a new diagnosis of osteoporosis about lifestyle modifications. Which of the following recommendations should the nurse include?
- A. Avoid weight-bearing exercises.
- B. Limit calcium intake to 800 mg per day.
- C. Perform daily stretching exercises.
- D. Stop smoking and limit alcohol intake.
Correct Answer: D
Rationale: smoking cessation and limiting alcohol reduce bone loss and fracture risk in osteoporosis
Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.
- A. Ask the client to open and close the hand until the skin blanches.
- B. Palpate the ulnar and radial pulses and apply pressure to both arteries.
- C. Observe the hand for color.
- D. Release the ulnar artery while maintaining pressure on the radial artery.
Correct Answer: A,B,D,C
Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.