Nokea
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.
- A. 18%
- B. 23%
- C. 32%
- D. 36%
Correct Answer: B
Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.
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The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.
The doctor has ordered 80 mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5 meq/L. The nurse should:
- A. Administer the Lasix as ordered
- B. Administer half the dose
- C. Offer the patient a potassium-rich food
- D. Withhold the drug and call the doctor
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L is dangerously low; withholding Lasix and notifying the doctor prevents further potassium loss.
Based on clinical findings, the physician suspects that a 65-year-old client has kidney disease and has ordered a blood-urea-nitrogen (BUN) test. Which of the following results is within normal limits?
- A. 5 mg/dL
- B. 15 mg/dL
- C. 40 mg/dL
- D. 100 mg/dL
Correct Answer: B
Rationale: Normal BUN is 7-20 mg/dL, so 15 mg/dL (B) is within range. Other values (A, C, D) are too low or high.
The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?
- A. Heart rate of 140 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Presence of milia on the nose.
- D. Caput succedaneum crossing the suture line.
Correct Answer: C
Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn