Nokea
The nurse understands that the pathophysiology of a thermal injury includes (Select All that Apply):
- A. Hematuria
- B. Edema
- C. Hypovolemia
- D. Anemia
Correct Answer: B,C
Rationale: The correct answers are B: Edema and C: Hypovolemia. Edema occurs due to increased capillary permeability after a thermal injury, leading to fluid leakage into tissues. Hypovolemia results from fluid shift out of the blood vessels into the injured tissues, causing decreased blood volume. Hematuria (A) is not typically associated with thermal injuries. Anemia (D) is a decrease in the number of red blood cells or hemoglobin, not a direct result of thermal injury.
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Fentanyl 30mcg IV is ordered. The vial contains 0.05mg/ml. How many ml should the nurse administer?
- A. 0.3 ml
- B. 3 ml
- C. 0.06 ml
- D. 0.6 ml
Correct Answer: D
Rationale: To calculate the amount of Fentanyl to administer, first convert 30mcg to mg by dividing by 1000 (30mcg = 0.03mg). Then, divide the dose by the concentration of the vial (0.03mg ÷ 0.05mg/ml = 0.6ml). The correct answer is D (0.6ml). Choice A (0.3ml) is incorrect because it doesn't account for the correct dosage calculation. Choice B (3ml) is incorrect as it is too high, leading to potential overdose. Choice C (0.06ml) is incorrect as it miscalculates the dosage based on the vial concentration.
A child admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n):
- A. Chemical burn
- B. Inhalation injury
- C. Electrical burn
- D. Hot-water scald
Correct Answer: B
Rationale: The correct answer is B: Inhalation injury. The presence of burns on the lips and singed nasal hairs indicate that the child has likely inhaled hot gases or smoke, which can cause damage to the respiratory tract. This is a common finding in cases of inhalation injury resulting from exposure to fire or smoke. Inhalation injury can lead to airway compromise, respiratory distress, and other serious complications. The other choices (A: Chemical burn, C: Electrical burn, D: Hot-water scald) do not specifically indicate damage to the respiratory tract, making them less likely in this scenario.
When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of:
- A. Asthma
- B. Nephrosis
- C. Otitis media
- D. Neurotoxicity
Correct Answer: A
Rationale: The correct answer is A: Asthma. Atopic dermatitis is commonly associated with other allergic conditions, such as asthma. Asking about a history of asthma can help identify potential triggers and comorbidities. Nephrosis, otitis media, and neurotoxicity are not typically associated with atopic dermatitis, making choices B, C, and D incorrect. Always focus on relevant factors to provide effective care.
A child being administered a new medication displays signs of an adverse drug reaction. The nurse would expect treatment of the reaction to include (Select all that apply):
- A. Administering antibiotics
- B. Discontinuing the drug
- C. Administering antihistamines
- D. Administering corticosteroids
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Discontinuing the drug is essential to stop the adverse reaction. Administering antihistamines helps manage symptoms like itching and hives. Corticosteroids can reduce inflammation and allergic responses caused by the reaction. Antibiotics (choice A) are not indicated unless there is a specific infection requiring treatment. No other choices were provided, but it's crucial to focus on stopping the offending drug, managing symptoms, and addressing inflammation in the case of an adverse drug reaction.
A 3-year-old patient is taking therapeutic doses of Digoxin and Lasix for heart failure and has an order for daily labs to be drawn. What side effect of this drug combination would the nurse find most concerning?
- A. Hypernatremia
- B. Hypokalemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Hypokalemia. Digoxin and Lasix can both cause potassium loss, leading to hypokalemia. In this case, hypokalemia is concerning as it can increase the risk of Digoxin toxicity, resulting in life-threatening arrhythmias. Hypernatremia (A), hyponatremia (C), and hyperkalemia (D) are not common side effects of this drug combination and would not pose the same level of risk as hypokalemia.