Nokea
What would the nurse anticipate to be prescribed for a client with a suspected inhalation injury at home?
- A. 100% oxygen via an aerosol mask
- B. Oxygen via nasal cannula at 6 L/minute
- C. Oxygen via nasal cannula at 15 L/minute
- D. 100% oxygen via a tight-fitting, nonrebreather face mask
Correct Answer: D
Rationale: In cases of suspected inhalation injury, providing high concentrations of oxygen is crucial to counteract potential hypoxia and carbon monoxide poisoning. A nonrebreather mask can deliver close to 100% oxygen.
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The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication?
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Coldness of the extremity and crepitus.
- D. Palpable radial pulse and functional movement.
Correct Answer: A
Rationale: Numbness and mottled cyanosis suggest neurovascular compromise, a serious complication requiring immediate attention.
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority?
- A. Altered body image
- B. Activity intolerance
- C. Impaired coping
- D. Fluid volume deficit
Correct Answer: D
Rationale: Adrenal gland infection in AIDS can impair cortisol and aldosterone production, leading to fluid volume deficit, a life-threatening priority.
The client is diagnosed with Meniere's disease. Which statement indicates the client understands the medical management for this disease?
- A. After intravenous antibiotic therapy, I will be cured.
- B. I will have to use a hearing aid for the rest of my life.
- C. I must adhere to a low-sodium diet, 2,000 mg/day.
- D. I should sleep with the head of my bed elevated.
Correct Answer: C
Rationale: A low-sodium diet reduces fluid retention in the inner ear, helping manage Meniere's disease symptoms like vertigo and hearing loss.
The nurse provides discharge instructions to a client following patch testing. Which instruction would the nurse provide to the client?
- A. return to the clinic in 2 weeks for the initial reading
- B. reapply the patch if it comes off
- C. continue all current activities
- D. keep the test sites dry
Correct Answer: D
Rationale: Keeping patch test sites dry ensures accurate results; readings typically occur at 48 hours and 96 hours, not 2 weeks.
When reading the admission assessment for a patient, the nurse notes that the patient has an excoriated area on the skin of the right forearm. Which nursing action will be included in the plan of care?
- A. Apply moisturizing lotion to the area.
- B. Assess the area daily for atrophy.
- C. Scrub the affected area vigorously.
- D. Cover the area with a sterile dressing.
Correct Answer: D
Rationale: Excoriated areas should be covered with a dressing to decrease the risk for infection. Application of moisturizer would not help the excoriation and might lead to infection. There is no evidence that the skin is atrophied. Scrubbing the excoriated area would cause further damage.