Nokea
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.
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A client is admitted with suspected fracture of the left hip. The most consistent finding in the client with the hip fracture is:
- A. Pain in the hip and affected leg
- B. Absence of pedal pulses
- C. Disalignment of the leg
- D. Diminished sensation
Correct Answer: C
Rationale: Disalignment of the leg , such as shortening or external rotation, is the most consistent sign of a hip fracture. Pain is common but less specific. Pulses and sensation are typically intact.
A patient is being treated in the telemetry unit for cardiac disease. The patient is to receive propranolol hydrochloride (Inderal) 20 mg PO at 9 AM. The nurse finds him wheezing with a nonproductive cough and shortness of breath.
INITIALLY, the nurse should
- A. hold the medication and count the respirations.
- B. hold the medication and call the physician.
- C. take an apical pulse and then give the medication.
- D. give the medication as ordered.
Correct Answer: A
Rationale: Strategy: Determine the outcome of each answer choice. (1) correct-side effects include increased airway resistance, patient is experiencing bronchospasm, should assess then call the physician (2) should assess the patient's condition first (3) experiencing a side effect, medication should not be given (4) medication should be held, experiencing a side effect
To minimize the side effects of a DPT immunization for a six-month-old.
The nurse should instruct the parents to
- A. give the child an alcohol bath for an elevated temperature.
- B. administer antipyretics for discomfort, irritability, and fever.
- C. place an ice bag on the child's leg for one hour.
- D. check the child's temperature every four hours for three days.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason
A client who has a strong family history of breast cancer tells the nurse that she is taking a drug to prevent breast cancer. The nurse expects the drug that she is receiving is:
- A. Tamoxifen (Nolvadex)
- B. Cyclophosphamide (Cytoxan)
- C. Estrogen (Premarin)
- D. Doxorubicin (Adriamycin)
Correct Answer: A
Rationale: Tamoxifen is used for breast cancer prevention in high-risk individuals due to its anti-estrogenic effects. Cyclophosphamide and Doxorubicin are chemotherapy drugs, not preventive, so B and D are incorrect. Estrogen can increase breast cancer risk, making C incorrect.
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.