Nokea
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct Answer: A
Rationale: Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet.
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The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
Hazards of improper splinting include:
- A. aggravation of a bone or joint injury
- B. reduced distal circulation
- C. delay in transport of a client with a life-threatening injury
- D. all of the above
Correct Answer: D
Rationale: Improper splinting can worsen injuries, impair circulation, and delay critical transport, posing significant risks to the client.
The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these would be an appropriate action taken by the nurse?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct Answer: A
Rationale: Referred pain in the ear is normal after a tonsillectomy because of related nerve pathways. Vitals should be monitored every 15 minutes in the immediate postoperative period and then every 4 hours thereafter. Straws and hot beverages should be avoided as they may irritate the throat and disturb healing.
Which of the following statements indicates that the nurse understands how to promote rest and sleep for the client?
- A. If you would prefer to not be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
- B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
- C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
- D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.
Correct Answer: C
Rationale: To promote rest and sleep, the nurse should try to incorporate any client preferences into the evening routine.
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
- A. Encourage foods high in vitamin C such as orange juice
- B. Premedicate with analgesics prior to dressing changes
- C. Monitor pedal pulses and capillary refill of affected extremity
- D. Use hydrogen peroxide for cleaning of the ulcer wound
- E. Turn and reposition the client every 1 to 2 hours
- F. Elevate the extremity on pillows, keeping the heel off the pillow
Correct Answer: A,B,C,E,F
Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.