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: safety is a priority for the client who is at high risk for infection
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Arterial ulcers are best described as ulcers that:
- A. Are smooth in texture
- B. Have irregular borders
- C. Are cool to touch
- D. Are painful to touch
Correct Answer: D
Rationale: Arterial ulcers are typically painful due to poor blood flow and tissue ischemia.
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
- A. every 15 minutes.
- B. every 30 minutes.
- C. every hour.
- D. every 2 hours.
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (C) balance safety and practicality.
The nurse is preparing to administer levofloxacin (Levaquin) 400 mg orally to a client with a urinary tract infection. Which statement by the client requires further teaching by the nurse?
- A. I will need to wear sunscreen if I am outdoors.
- B. I need to finish all the medication, even if my symptoms go away.
- C. I should take my antacid right before my pill so I don't get heartburn.
- D. I need to check my pulse twice daily and call my doctor if I have new-onset irregular heartbeats.
Correct Answer: C
Rationale: Antacids can reduce levofloxacin absorption and should be taken at least 2 hours apart. Other statements are correct.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.