Nokea
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
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A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
- A. Your child should also take an antihistamine.'
- B. The antibiotic is the only medicine necessary.'
- C. The ear in the ears helps the discomfort.'
- D. Over-the-counter eardrops often are helpful.'
Correct Answer: B
Rationale: Antibiotics are the primary treatment for bacterial ear infections; antihistamines and eardrops are not typically recommended unless prescribed.
Which statement about Respondeat Superior is accurate?
- A. Respondeat Superior does not mean that a nurse cannot be held liable.
- B. Respondeat Superior does not mean that a nurse cannot be held libel.
- C. Respondeat Superior is an ethical principle.
- D. Respondeat Superior is a law.
Correct Answer: A
Rationale: Respondeat Superior is a legal doctrine holding employers liable for employees' actions within the scope of employment, but it does not absolve nurses from personal liability for negligence.
The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?
- A. Vital signs
- B. Motor function
- C. Sensory function
- D. Level of consciousness
Correct Answer: D
Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.
A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?
- A. Administer pantoprazole intravenously.
- B. Insert a nasogastric tube.
- C. Administer vitamin K.
- D. Position the client supine.
Correct Answer: A
Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.
The nurse is caring for a client post-cataract surgery. Which instruction should the nurse include in discharge teaching?
- A. Avoid bending at the waist
- B. Resume driving immediately
- C. Wear glasses at all times
- D. Sleep on the operative side
Correct Answer: A
Rationale: Avoiding bending at the waist prevents increased intraocular pressure, which could complicate recovery post-cataract surgery.