Nokea
Which response by the nurse best explains why insulin must be given subcutaneously?
- A. The oral form of insulin can lead to the worsening of diabetes.
- B. The oral form of insulin is not yet available for use.
- C. Insulin is a protein that is destroyed by digestive enzymes.
- D. Insulin given by the oral route causes severe vomiting.
Correct Answer: C
Rationale: Insulin is a protein hormone that would be broken down by digestive enzymes in the gastrointestinal tract if taken orally, rendering it ineffective. Subcutaneous administration ensures it reaches the bloodstream intact.
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Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
Which nursing instruction concerning ice applications is appropriate to give the parents of a 12-year-old child with a sprained ankle?
- A. Ice can be applied and left on until the swelling is gone.
- B. Ice can be applied but must be removed every 30 minutes to 1 hour to check the ankle.
- C. Ice should not be used for treating sprains; heat should be used instead.
- D. There is no danger associated with the application of ice.
Correct Answer: B
Rationale: Ice should be applied intermittently (e.g., 20-30 minutes on, then off) to prevent tissue damage and allow skin assessment, making removal every 30 minutes to 1 hour appropriate.
Which assessment finding is most indicative of a child with a protein deficiency?
- A. Brittle hair and dry skin
- B. Frequent nosebleeds
- C. High fever and chills
- D. Rapid weight gain
Correct Answer: A
Rationale: Protein deficiency can lead to brittle hair and dry skin due to inadequate protein for tissue repair and maintenance, a hallmark of conditions like kwashiorkor.