Nokea
The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?
- A. Lower torso
- B. Upper part of the body
- C. Hands and feet
- D. Perineum
Correct Answer: B
Rationale: Burns to the upper body, including the chest and face, increase the risk of respiratory complications, such as airway obstruction or inhalation injury, which are life-threatening.
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Which statement would the nurse expect the client to report when looking at an object without wearing corrective glasses or contact lenses?
- A. I see near objects more clearly.
- B. I see a blurry area in front of me.
- C. I see far objects more clearly.
- D. I see two of the same object.
Correct Answer: B
Rationale: Astigmatism causes blurry or distorted vision due to irregular corneal curvature.
The nurse writes the client problem of 'acute pain and itching secondary to bacterial skin lesions.' Which interventions should be included in the care plan? Select all that apply.
- A. Keep humidity at less than 20%.
- B. Maintain a cool environment.
- C. Use a mild soap for sensitive skin.
- D. Keep lesions covered at all times.
- E. Apply skin lotion after bathing.
Correct Answer: B,C,E
Rationale: Cool environment, mild soap, and lotion reduce itching and pain in bacterial lesions. Low humidity worsens dryness, and constant coverage may trap moisture, promoting infection.
The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.
The nurse must withhold medication administration and notify the physician if which drug is ordered for a client with glaucoma?
- A. Atropine sulfate (Sal-Tropine)
- B. Morphine sulfate (Roxanol)
- C. Magnesium sulfate (Epsom salts)
- D. Ferrous sulfate (Feosol)
Correct Answer: A
Rationale: Atropine can increase intraocular pressure, worsening glaucoma.
The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching?
- A. I will check my skin every day for redness with tenderness.'
- B. I must take my psoralen medication two (2) hours before my treatment.'
- C. I will wear dark glasses during my treatment and the rest of the day.'
- D. The coal-tar ointments and lotions will not stain my clothes.'
Correct Answer: D
Rationale: Coal-tar ointments stain clothes, indicating a need for further teaching. Daily skin checks, psoralen timing, and dark glasses are correct for PUVA therapy.