Nokea
The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
- A. Ineffective airway clearance
- B. Impaired gas exchange
- C. Fluid volume deficit
- D. Pain
Correct Answer: C
Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.
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Which type of leukemia is more common in older adults?
- A. Acute myelocytic leukemia
- B. Acute lymphocytic leukemia
- C. Chronic lymphocytic leukemia
- D. Chronic granulocytic leukemia
Correct Answer: C
Rationale: Chronic lymphocytic leukemia (CLL) is most common in older adults, typically diagnosed in those over 60, due to its indolent nature and prevalence in this age group.
The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using:
- A. A toothbrush
- B. A soft gauze pad
- C. Antiseptic mouthwash
- D. Lemon and glycerin swabs
Correct Answer: B
Rationale: A soft gauze pad is gentle and effective for cleaning the mouth in oral candidiasis without causing trauma.
The nurse is teaching a client with a new diagnosis of migraine headaches about trigger avoidance. Which of the following should the client avoid?
- A. Regular exercise.
- B. Aged cheeses.
- C. Fresh fruits.
- D. Daily meditation.
Correct Answer: B
Rationale: aged cheeses contain tyramine, a common migraine trigger
The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's stomach placement?
- A. Aspiration of tan-colored mucus
- B. Green aspirate with a pH of 3
- C. A swish auscultated with the injection of air
- D. Bubbling in a cup of NS when the end of the tube is placed in the cup
Correct Answer: B
Rationale: A green aspirate with a pH of 3 confirms gastric placement, as stomach contents are acidic and often green due to bile, providing the most reliable indicator.
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
- A. Increased jaundice and prolonged prothrombin time
- B. Fever and foul-smelling bile drainage
- C. Abdominal distention and clay-colored stools
- D. Increased uric acid and increased creatinine
Correct Answer: A
Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.