Nokea
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
- A. Fat, tendons, and bones
- B. Skin and hair
- C. Nerves, muscle, and blood vessels
- D. Skin, fat, and muscle
Correct Answer: A
Rationale: Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury. Answer B has intermediate resistance, so it is incorrect. Answer C is incorrect because it has very low resistance. Answer D has low to intermediate resistance, so it is incorrect.
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Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
- A. Colace is prescribed to make it take longer for blood to clot.
- B. Colace makes it easier for the client to relax and reduce stress.
- C. Colace helps lower cholesterol levels.
- D. Colace reduces straining at stool.
Correct Answer: D
Rationale: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.
A client with a gastric ulcer compared to a friend's duodenal ulcer.
The nurse's response should be based on which of the following statements?
- A. Gastric ulcers have an increased association with clients who experience increased psychological pressures.'
- B. The pain of a duodenal ulcer usually occurs two to four hours after meals.'
- C. Clients with gastric ulcers often gain weight, as food alleviates the pain.'
- D. Antacids such as Maalox are seldom prescribed for clients with duodenal ulcers.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) refers to duodenal ulcers (2) correct-clients with duodenal ulcers experience pain after meals, e.g., midmorning and midafternoon (3) gastric ulcer clients may be malnourished because food may cause nausea or vomiting (4) antacids are given to duodenal ulcer clients
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client. The next action by the nurse should be to
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.