Nokea
The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?
- A. Respirations 24, unlabored
- B. Urine output of 30 mL/hr
- C. Capillary refill <4 seconds
- D. Apical pulse of 110/min
Correct Answer: B
Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.
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The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with methcillin resistant-staphylococcus aureas (MRSA)
- B. The client with diabetes
- C. The client with pancreatitis
- D. The client with Addison's disease
Correct Answer: A
Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:
- A. Telling the client's wife not to touch the tablets
- B. Explaining that the medication should be taken with meals
- C. Telling the client that symptoms will improve in 1-2 weeks
- D. Instructing the client to take the medication at bedtime, to prevent nocturia
Correct Answer: A
Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. This is a critical teaching point for safety.
The nurse is teaching a client with a new colostomy about dietary management. Which of the following foods should the nurse recommend the client avoid to reduce odor and gas?
- A. Broccoli.
- B. Baked chicken.
- C. Rice.
- D. Yogurt.
Correct Answer: A
Rationale: broccoli is a gas-forming food that can increase odor and gas in a colostomy
A client is to be discharged on warfarin (Coumadin®) therapy, and the nurse is teaching the client about the medication. Which of the following statements by the client indicates that the client's education has been effective? Select all that apply.
- A. I should use a soft toothbrush.
- B. My stools will routinely be black.
- C. Swimming is a good choice for exercise.
- D. I should wear a Medical Alert bracelet.
- E. I should avoid all green, leafy vegetables.
Correct Answer: A,C,D
Rationale: Soft toothbrush (A), swimming (C), and Medical Alert bracelet (D) reduce bleeding risk and ensure safety. Black stools (B) indicate bleeding, and avoiding all leafy greens (E) is excessive.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.