Nokea
The nurse is caring for a client with a history of burns covering 25% of the body. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor for signs of infection.
- B. Administer I.V. fluids as prescribed.
- C. Apply silver sulfadiazine to burns.
- D. Provide a low-protein diet.
- E. Administer analgesics as needed.
Correct Answer: A, B, C, E
Rationale: Monitoring for infection, I.V. fluids, silver sulfadiazine, and analgesics are essential for burn care. A high-protein diet is needed, not low-protein.
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A client with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates the medication is effective?
- A. Increased blood pressure.
- B. Decreased edema.
- C. Weight gain.
- D. Elevated potassium levels.
Correct Answer: B
Rationale: Furosemide is a diuretic that reduces fluid overload, so decreased edema indicates effective treatment by promoting fluid excretion.
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.
Which instruction should the nurse provide to the client prescribed the medication benztropine mesylate?
- A. Sit in the sun for 30 minutes daily.
- B. Avoid driving if drowsiness or dizziness occurs.
- C. Expect difficulty swallowing while taking this medication.
- D. Expect episodes of vomiting and constipation while taking this medication.
Correct Answer: B
Rationale: The client taking benztropine mesylate, anti-Parkinson's agent and anticholinergic agent, should be instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client's tolerance to heat may be reduced because of the diminished ability to sweat, and the client should be instructed to plan rest periods in cool places during the day. The client should be instructed to contact the primary health care provider immediately if difficulty swallowing or speaking or vomiting occurs. The client should also inform the primary health care provider if central nervous system effects occur. The client is instructed to monitor urinary output and watch for signs of constipation.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
A client wanders in and out of other clients' rooms, taking their possessions while singing to himself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action?
- A. Putting arms around the client, saying, 'You're okay. You just need a hug.'
- B. Saying, 'I can see you are very anxious today. Let's go and play the piano.'
- C. Taking the client to the seclusion room until he cooperates with unit rules.
- D. Taking the client to the lounge and saying, 'Sit here and try to behave yourself.'
Correct Answer: B
Rationale: The use of a defense mechanism allows a person to avoid the painful experience of anxiety or transform it into a more tolerable symptom, such as regression. Regression allows the threatened client to move backward developmentally to a stage in which more security is felt. The recognition of regression is a signal that the client feels anxious. The correct option will help the client feel less anxious. A hug does not address the client's anxiety. The remaining options are restrictive and degrading.