Nokea
Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirl pool bath and dressing change?
- A. Soak the dressing.
- B. Remove the dressing.
- C. Administer an analgesic.
- D. Slit the dressing with blunt scissors.
Correct Answer: C
Rationale: Administering an analgesic 30 minutes before a painful procedure like a whirlpool bath and dressing change ensures pain relief, improving patient comfort and cooperation. Soaking, removing, or slitting the dressing typically occurs during the procedure, not beforehand.
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Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.
The emergency department (ED) nurse is caring for a client with acetaminophen toxicity. The nurse anticipates a prescription for which medication?
- A. acetylcysteine
- B. deferoxamine mesylate
- C. succimer
- D. flumazenil
Correct Answer: A
Rationale: Acetylcysteine is the antidote for acetaminophen toxicity, protecting the liver by restoring glutathione levels.
Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
A priority in the first 24 hours after a bilateral adrenalectomy is:
- A. Beginning oral nutrition.
- B. Promoting self-care activities.
- C. Preventing adrenal crisis.
- D. Ambulating in the hallway.
Correct Answer: C
Rationale: Preventing adrenal crisis is critical post-adrenalectomy due to sudden loss of adrenal hormone production, requiring steroid replacement.