Nokea
The nurse is ordered to insert an indwelling catheter in a severely burned client for which reason?
- A. To prevent contamination of burned areas
- B. To measure hourly urine output
- C. To prevent urinary tract infection
- D. To detect internal injuries quickly
Correct Answer: B
Rationale: An indwelling catheter is used to measure hourly urine output, which guides fluid resuscitation to prevent shock in severe burn clients.
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On inspecting the client's eye, the nurse will note which symptom of conjunctivitis in addition to erythema?
- A. Dried drainage along the eyelid
- B. Lack of pupil response to light
- C. Bulging of the eye from the orbit
- D. Loss of moisture on the cornea
Correct Answer: A
Rationale: Conjunctivitis often presents with dried, crusty drainage along the eyelid.
Of the following information provided by the client to the nurse, which factor is most likely to cause a retinal detachment?
- A. The client is younger than age 40.
- B. The client fell and struck the head.
- C. The client has multiple allergies.
- D. The client is being treated for glaucoma.
Correct Answer: B
Rationale: Trauma, such as a head injury, is a common cause of retinal detachment.
If a client with a middle ear infection reports the following symptoms, which one suggests that the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
The nurse is working with clients in an aesthetic surgery center. Which intervention should the nurse implement for a client undergoing a chemical peel?
- A. Teach the client to expect extreme swelling after the procedure.
- B. Apply the chemical mixture directly to skin after the face is cleansed.
- C. Administer general anesthesia to the client prior to the procedure.
- D. Explain that there will be no pain or discomfort during the procedure.
Correct Answer: B
Rationale: Applying the chemical post-cleansing ensures efficacy and safety. Extreme swelling is not typical, general anesthesia is unnecessary, and mild discomfort is expected.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.