Nokea
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.
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The nurse is caring for a client with a history of congestive heart failure (CHF). Which of the following findings would indicate to the nurse that the client's condition is worsening?
- A. Clear lung sounds bilaterally.
- B. Weight gain of 2 pounds in 24 hours.
- C. Urine output of 1,200 mL in 24 hours.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: weight gain is a sign of fluid retention, indicating worsening CHF
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.
The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?
- A. Measures the circulatory volume in the coronary arteries.
- B. Indirectly measures the pressure in the ventricles.
- C. Analyzes the adequacy of pulmonary circulation.
- D. Directly measures the adequacy of CO2 exchange.
Correct Answer: B
Rationale: CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client reports increased shortness of breath. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Check the client's oxygen saturation.
- C. Place the client in a supine position.
- D. Administer a bronchodilator as ordered.
Correct Answer: B
Rationale: checking oxygen saturation provides objective data to assess the client's respiratory status
A client has an order for a low-sodium, low-cholesterol diet. The nurse knows that which of the following selections reflects the client's compliance?
- A. Canned vegetable soup, applesauce, and hot chocolate.
- B. Cheeseburger, french fries, and skim milk.
- C. Tomato and lettuce salad, roasted chicken, and lemonade.
- D. Tuna fish sandwich, cottage cheese, and a cola.
Correct Answer: C
Rationale: fresh fruits and vegetables are low sodium, roasted chicken is low cholesterol