Nokea
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.
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The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
- A. Estimate the amount of burned area using the rule of nines.
- B. Insert two (2) 18-gauge catheters and begin fluid replacement.
- C. Apply sterile saline dressings to the burned areas.
- D. Determine the client’s airway status.
- E. Administer morphine sulfate, IV.
Correct Answer: D,B,E,A,C
Rationale: Priority: 1) Airway status (ABCs); 2) IV catheters/fluids (prevent shock); 3) Morphine (pain control); 4) Rule of nines (guide resuscitation); 5) Sterile dressings (infection prevention).
The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- A. Tinea capitis.
- B. Herpes simplex 2.
- C. Scabies.
- D. Psoriasis.
Correct Answer: C
Rationale: Itching and threadlike burrows between fingers indicate scabies. Tinea capitis affects the scalp, HSV-2 is genital, and psoriasis causes plaques.
The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose?
Correct Answer: 250
Rationale: 220 lbs ÷ 2.2 = 100 kg; 10 mg/kg/day = 1000 mg/day; 1000 mg ÷ 4 doses = 250 mg/dose.
The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex). Which instructions should the nurse teach?
- A. This medication will prevent pregnancy and treat the virus.
- B. This medication must be tapered when discontinuing the medication.
- C. This medication will suppress symptoms but does not cure the disease.
- D. This medication may cause the client’s urine to turn orange.
Correct Answer: C
Rationale: Valacyclovir suppresses HSV-2 symptoms but does not cure it. It does not prevent pregnancy, require tapering, or change urine color.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
- A. Replace fluids and electrolytes.
- B. Prevent contractures of extremities.
- C. Monitor urine output hourly.
- D. Prepare to assist with an escharotomy.
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.