Nokea
Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.
- A. Applies zinc oxide to the client's perineal skin
- B. Provides a donut pillow while the client is sitting in the chair
- C. Maintain the head of the client's bed at 90 degrees
- D. Encourages the client to consume foods rich in carbohydrates
- E. Uses a pillow to float the client's heels
Correct Answer: B, C
Rationale: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.
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The nurse cares for a 29-year-old male in the emergency department (ED)
Item 5 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse should plan to obtain a prescription for ………………….. to restore circulating volume. The ……………………… will be used to determine the 24-hour fluid requirement. To measure the effectiveness of the fluid replacement, the nurse plans to …………………………..
- A. 0.45% saline
- B. Dextrose 5% Water (D5W)
- C. Lactated ringers
- D. Parkland formula
- E. pulmonary function tests
- F. TNM staging
- G. insert an indwelling urinary catheter
Correct Answer: C, D, G
Rationale: Lactated Ringers restores circulating volume, the Parkland formula calculates fluid needs, and a urinary catheter monitors output to assess fluid replacement effectiveness.
The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply.
- A. Pronounced wrinkles on the face
- B. Decreased size of the nose and ears
- C. Increased growth of facial hair
- D. Neck wrinkles
- E. Increased height
Correct Answer: A, C, D
Rationale: Aging causes pronounced wrinkles on the face and neck and increased facial hair due to hormonal changes. Nose and ears enlarge, and height decreases due to spinal compression.
Place the following actions in the order in which they need to be performed, starting with the highest priority action.
- A. Initiate a large-bore peripheral vascular access device
- B. Perform a respiratory assessment and inspect the client's nose and mouth
- C. Administer prescribed intravenous (IV) pain medication
- D. Administer prescribed intravenous (IV) fluids
- E. Perform wound care to the affected area(s)
Correct Answer: B, A, D, C, E
Rationale: Respiratory assessment is first to ensure airway patency, followed by IV access and fluids for resuscitation, pain medication for comfort, and wound care last.
The nurse recognizes that rewarming a client with hypothermia must be done slowly to prevent
- A. Superficial burns
- B. ventricular fibrillation
- C. frostbite
- D. muscle spasms
Correct Answer: B
Rationale: Rapid rewarming can cause ventricular fibrillation due to sudden changes in core temperature affecting cardiac rhythm. Slow rewarming helps stabilize the cardiovascular system.
The nurse documents the presence of a skin lesion as a 'palpable solid mass measured at 1 cm.' What types of skin lesions might this describe? Select all that apply.
- A. Macule
- B. Patch
- C. Plaque
- D. Nodule
- E. Bulla
- F. Pustule
Correct Answer: C, D
Rationale: A palpable solid mass of 1 cm could be a plaque (elevated, >1 cm) or nodule (solid, deeper, 0.5-2 cm). Macules and patches are flat, bullae are fluid-filled, and pustules contain pus.