Nokea
The nurse suspects that the client's anxiety is due to fear that nursing care will intensify symptoms. Which nursing intervention is most appropriate to add to the care plan?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.
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The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL X weight in kg X % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? mL of IV fluid (Record your answer as a whole number.)
- A. 4000
Correct Answer: A
Rationale: Use the Parkland formula provided: 4.0 mL at 50 kg = 200 mL; 200 mL × 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn.
The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement?
- A. Encourage the use of support stockings.
- B. Administer a topical anti-inflammatory cream.
- C. Remove scales frequently by shampooing.
- D. Shampoo with lindane 1%, an antiparasitic, weekly.
Correct Answer: B
Rationale: Topical anti-inflammatory cream (e.g., steroids) treats contact dermatitis. Stockings, scale removal, and lindane are irrelevant.
A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?
- A. With a sterile, gloved hand
- B. With a sterile applicator
- C. With sterile 4x4's
- D. By aerosol spray
Correct Answer: C
Rationale: Sulfamylon is applied using sterile 4x4 gauze pads to ensure even coverage and maintain sterility while minimizing pain.
The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer.
- B. Refer the client to a prosthesis specialist for prosthesis.
- C. Instruct the client how to apply sunscreen to the area.
- D. Demonstrate care of the surgical site.
Correct Answer: D
Rationale: Surgical site care prevents infection and promotes healing. Ongoing cancer risk remains, prostheses are irrelevant, and sunscreen is secondary post-surgery.
The nurse must withhold medication administration and notify the physician if which drug is ordered for a client with glaucoma?
- A. Atropine sulfate (Sal-Tropine)
- B. Morphine sulfate (Roxanol)
- C. Magnesium sulfate (Epsom salts)
- D. Ferrous sulfate (Feosol)
Correct Answer: A
Rationale: Atropine can increase intraocular pressure, worsening glaucoma.