Nokea
The nurse should plan to begin rehabilitation efforts for the burn client:
- A. Immediately after the burn has occurred.
- B. After the client's circulatory status has been stabilized.
- C. After the client's pain has been eliminated.
- D. After the client's pain has been eliminated.
Correct Answer: B
Rationale: Rehabilitation begins after stabilizing the client's circulatory status (emergent phase), as this ensures survival and allows focus on recovery. Immediate rehab is unsafe, and complete pain elimination is unrealistic.
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The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.
Which of the following is a risk factor for hypovolemic shock?
- A. Hemorrhage.
- B. Antigen-antibody reaction.
- C. Gram-negative bacteria.
- D. Vasodilation.
Correct Answer: A
Rationale: Hemorrhage is a primary cause of hypovolemic shock, as it reduces circulating blood volume. Antigen-antibody reactions cause anaphylactic shock, gram-negative bacteria cause septic shock, and vasodilation is a feature of distributive shock.
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
- A. Apply a half-leg pneumatic compression device
- B. Suggest the client contact her physician
- C. Assess the client for foot ulcers
- D. Encourage the client to avoid standing in one position for long periods of time
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
- A. 1
- B. 2
- C. 3
- D. 4
- E. 5
Correct Answer: A
Rationale: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
Which of the following reasons explains why meperidine (Demerol) is not recommended for chronic cancer-related pain?
- A. It has a high potential for abuse.
- B. It has agonist-antagonist properties.
- C. It must be given intramuscularly to be effective.
- D. It contains a metabolite that causes seizures.
Correct Answer: D
Rationale: Meperidine's metabolite, normeperidine, accumulates with repeated dosing and can cause seizures, making it unsuitable for chronic cancer pain.