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The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
- A. Superficial partial-thickness.
- B. Full-thickness.
- C. Deep partial-thickness.
- D. Deep full-thickness.
Correct Answer: B
Rationale: A painless, brown/yellow, swollen burn indicates full-thickness damage, involving the epidermis and dermis.
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A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.
A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?
- A. Maintain the prescribed fluid restriction.
- B. Withhold the next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Assess for increasing fluid volume overload.
Correct Answer: A
Rationale: Maintaining fluid restriction is key in SIADH to prevent further sodium dilution, supporting the patient's improving sodium levels.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
- A. Elevate the head of the bed.
- B. Initiate a bowel prep protocol for surgery.
- C. Educate the patient on increasing dietary fiber.
- D. Maintain the patient's NPO status.
Correct Answer: D
Rationale: Maintaining NPO status rests the bowel, promoting healing during acute diverticulitis.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.