Nokea
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
You may also like to solve these questions
A client with a history of rheumatoid arthritis is prescribed leflunomide (Arava). The nurse should monitor the client for which of the following side effects?
- A. Liver toxicity.
- B. Hypotension.
- C. Weight loss.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Leflunomide can cause liver toxicity, requiring regular monitoring of liver function tests.
A client with a history of depression is prescribed duloxetine (Cymbalta). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Duloxetine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
- A. Administer aspirin as ordered.
- B. Assess neurological status.
- C. Prepare for a CT scan.
- D. Monitor blood pressure.
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client has a need for further teaching if the client makes which statement?
- A. An anesthetic throat spray will be used.
- B. A signed informed consent is necessary.
- C. Medication will be given orally for sedation.
- D. It is important to lie still during the procedure.
Correct Answer: C
Rationale: Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.
The nurse judges that the parents of a newborn with imperforate anus know what a low defect is when they say that the rectum:
- A. Is below the abdominal rectus muscle
- B. Is above the abdominal rectus muscle
- C. Has descended through the puborectalis muscle
- D. Has ascended through the puborectalis muscle
Correct Answer: C
Rationale: A low defect in imperforate anus means the rectum has descended through the puborectalis muscle, indicating a less severe anomaly. Other options describe incorrect anatomical positions.