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The nurse is teaching parents measures to prevent scald and burn injuries to toddlers in the home. Due to toddlers' inquisitiveness, which recommendation by the nurse is most important?
- A. Turn pot handles toward the back of the stove.
- B. Use the microwave cautiously when cooking.
- C. Ensure that the smoke detector is on and working.
- D. Verify that the bathwater temperature is tepid.
Correct Answer: A
Rationale: Turning pot handles back prevents toddlers from grabbing them, addressing their curiosity and reducing scald risks.
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A nurse is reviewing a patient's ECG report. The patient exhibits a flat T wave, depressed ST segment and short QT interval. Which of the following medications can cause all of the above effects?
- A. Morphine
- B. Atropine
- C. Procardia
- D. Digitalis
Correct Answer: D
Rationale: Digitalis can cause all of the listed ECG changes, including flat T waves, depressed ST segments, and shortened QT intervals, due to its effects on cardiac electrophysiology.
A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
- A. focus on reality orientation to place and person
- B. assist with the report of the client's complaint to the police
- C. obtain more details of the client's claim of abuse
- D. document the statement on the client's chart with a report to the manager
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.
- A. Places the bed in the lowest position
- B. Raises the head of the bed (HOB)
- C. Rolls onto the left side
- D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer: C,D
Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.
A patient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct Answer: A
Rationale: The shock phase is considered the first 24-48 hours in burn wound management.
A client states, 'People think I'm no good, you know what I mean?' Which of these responses would be most therapeutic?
- A. Well people often take their own feelings of inadequacy out on others.'
- B. I think you're good. So you see, there's one person who likes you.'
- C. I'm not sure what you mean. Tell me a bit more about that.'
- D. Let's discuss this to see the reasons you create this impression on people.'
Correct Answer: C
Rationale: I'm not sure what you mean. Tell me a bit more about that.' This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.