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Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube?
- A. Electrical burns of the hands and arms causing arrhythmias.
- B. Thermal burns to the head, face, and airway resulting in hypoxia.
- C. Chemical burns on the chest and abdomen.
- D. Secondhand smoke inhalation.
Correct Answer: B
Rationale: Thermal burns to the head, face, and airway can cause swelling and obstruction, leading to hypoxia and requiring airway management like endotracheal intubation or tracheostomy.
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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply.
- A. A 32-year-old female who delivered a 9½-lb infant.
- B. A 44-year-old Native American Indian who has a body mass index (BMI) of 32.
- C. An 18-year-old Hispanic who jogs four times a week.
- D. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.
- E. A 12-year-old who is overweight.
Correct Answer: A,B,D,E
Rationale: Risk factors for type 2 diabetes include history of delivering a large infant, obesity (BMI >30), family history, hypertension, and being overweight, especially in youth. Regular exercise reduces risk, making the 18-year-old less likely to be at risk.
A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
The nurse is preparing to apply a prescribed nitroglycerin ointment to a client. The nurse should?
- A. apply it only to the client's upper chest.
- B. rub the ointment into the client's skin until it disappears.
- C. rotate the application sites.
- D. cover the ointment with a gauze dressing.
Correct Answer: C
Rationale: Rotating sites prevents skin irritation and ensures consistent absorption.
The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate?
- A. Have you ever had any reactions to local anesthetics in the past?
- B. What is it that disturbs you about the idea of being awake?
- C. With a local anesthetic, you won't have nausea and vomiting after the surgery.
- D. There's really nothing to fear about being awake. You'll be given a medication that will help you relax.
Correct Answer: B
Rationale: The nurse should give a client who seems fearful of surgery an opportunity to express her feelings. Only after identifying the client's concerns can the nurse address them appropriately. Asking about previous reactions to anesthetics or discussing nausea does not address the client's fear. Minimizing the client's feelings by saying there is nothing to fear ignores her concerns.