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The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding.
A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room.
C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication.
D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.
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The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
- A. Weights every day .
- B. Blood pressure every 15 minutes
- C. Urinary output every hour
- D. Extent of peripheral edema every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
- A. Helping the client cope with body image
- B. Maintaining a patent airway.
- C. Preventing injury.
- D. Ensuring adequate nutrition.
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.