Nokea
Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
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When examining the electrical burn on the victim, which assessment is most important for the nurse to determine?
- A. The entry and exit wound sites
- B. Degree of skin discoloration
- C. Amount of eschar on the wound bed
- D. Characteristics of wound drainage
Correct Answer: A
Rationale: Identifying entry and exit sites assesses the extent of internal tissue damage.
Which question is most appropriate for the nurse to ask at this time?
- A. What childhood diseases have you had?
- B. What's your present occupation?
- C. Do you eat a well-balanced diet?
- D. How much aspirin do you take?
Correct Answer: D
Rationale: Excessive aspirin use can cause tinnitus, making it the most relevant question.
Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Aside from blood on the anterior end of the packing, what other sign or symptom would suggest that the client is bleeding from the operative area?
- A. Frequent swallowing
- B. Impaired appetite
- C. Slight hoarseness
- D. Diminished hearing
Correct Answer: A
Rationale: Frequent swallowing may indicate blood trickling down the throat.