Nokea
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
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A 68-year-old man is diagnosed with myasthenia gravis. The nurse instructs the client about his disease. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching?
- A. I should not drink alcoholic beverages.
- B. I should not go places that are crowded.
- C. I should try to stay calm.
- D. I should use my hot tub daily.
Correct Answer: D
Rationale: Hot tubs cause heat exposure, which can exacerbate myasthenia gravis symptoms, indicating a need for further teaching. Options A, B, and C are correct: alcohol worsens symptoms, crowds increase infection risk, and stress can trigger exacerbations.
A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
While teaching the client about the importance of prenatal vitamins.
The nurse should tell the client to take the vitamins
- A. with orange juice at bedtime.
- B. at breakfast with coffee.
- C. with milk at lunch.
- D. with water at dinner.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-taking the vitamins with something acidic increases the absorption of iron, taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins
A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased skin turgor. The woman's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory Test s indicate the serum sodium is 150 mEq/L and the Hct is 48%.
The nurse would expect the physician to order which of the following IV fluids?
- A. D5 NS.
- B. 0.45% NaCl.
- C. 0.9% NaCl.
- D. Lactated Ringer's.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hypertonic solutions contraindicated in dehydration (2) correct-hypotonic solution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any skin rash
- C. Stop the medication if seizures stop
- D. Avoid regular blood Test s
Correct Answer: B
Rationale: A skin rash may indicate Stevens-Johnson syndrome, a serious lamotrigine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks seizures, and blood Test s are needed.