Nokea
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. White blood cell (WBC) count.
- B. Hematocrit.
- C. Blood pH level.
- D. Platelet count.
Correct Answer: A
Rationale: Reviewing the white blood cell count is important because purulent drainage suggests infection, and an elevated WBC count may indicate an inflammatory response to infection.
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Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.
Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?
- A. Methotrexate slows the disease progression while aspirin controls the symptoms.
- B. Methotrexate helps to reduce the side effects of the aspirin therapy.
- C. Methotrexate enhances the effectiveness of the aspirin.
- D. Methotrexate has less harmful side effects than aspirin.
Correct Answer: A
Rationale: Methotrexate slows the progression of rheumatoid arthritis by suppressing immune responses, while aspirin provides symptomatic relief from pain and inflammation.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Alternate IV and IM analgesic medications.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Educate client on signs and symptoms of narcotic dependency.
Correct Answer: B
Rationale: Administering opioid and non-opioid medication simultaneously addresses severe pain from multiple pathways, providing effective relief for stage IV bone cancer.
A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 125
Correct Answer: A
Rationale: To calculate the infusion rate: 1000 mL / 8 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.