Nokea
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor urine output.
- B. Administer tetanus prophylaxis.
- C. Provide psychological support.
- D. Restrict visitors to prevent infection.
- E. Apply cold compresses to burns.
Correct Answer: A, B, C
Rationale: Monitoring urine output, tetanus prophylaxis, and psychological support are essential. Visitors should be screened, not restricted, and cold compresses are contraindicated.
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A client with no history of immunosuppressive disease has a Mantoux tuberculin skin test. The results indicate an area of induration that is 8 mm in size. How should the nurse interpret this result?
- A. Active tuberculosis
- B. A negative response
- C. A history of tuberculosis
- D. Past exposure to tuberculosis
Correct Answer: B
Rationale: Induration of 15 mm or more is considered positive for clients in low-risk groups. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency virus infection, persons with organ transplants, persons in close contact with a known case of tuberculosis, and those with a chest x-ray study suggestive of previous tuberculosis. More than 10 mm of induration is considered positive in all other high-risk groups, such as intravenous drug users.
A client with a history of heart failure is admitted with jugular vein distension. The nurse should include which of the following in the plan of care?
- A. Administer furosemide as prescribed.
- B. Position the client in Fowler's position.
- C. Restrict sodium intake.
- D. Encourage ambulation.
Correct Answer: A, B, C
Rationale: Furosemide, Fowler's position, and sodium restriction reduce fluid overload in heart failure.
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 with a history of type 2 diabetes mellitus is prescribed sitagliptin (Januvia). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
The nurse is providing care to the client who has received medication therapy with tissue plasminogen activator. Which item should the nurse have available for use as part of standard nursing care for this client?
- A. Flashlight
- B. Pulse oximeter
- C. Suction equipment
- D. Occult blood test strips
Correct Answer: D
Rationale: Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.