Quiz 6 Flashcards
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?
A. Infection
B. Airway obstruction
C. Paralytic ileus
D. Fluid imbalance
B. Airway obstruction
Describe the rule of 9s
Head (entire one side only) 4.5%
Chest (entire one side only) 9%
Abdomen (entire one side only) 9%
Upper back (entire one side only) 9%
Lower back (entire one side only) 9%
One arm (entire one side only) 4.5%
Groin 1%
Leg (entire one side only) 9%
Question rule of 9s
31.5%
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
A. Administer intravenous pain medication.
B. Draw blood for a complete blood cell (CBC) count.
C. Insert an indwelling urinary catheter.
D. Inspect the mouth for signs of inhalation injuries.
D. Inspect the mouth for signs of inhalation injuries.
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the client’s burns?
A. Age of the client
B. Associated medical history
C. Cause of the burn
D. Location of the burn
D. Location of the burn
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?
A. Administer pain medication.
B. Administer a tetanus booster.
C. Clean and dress the wound.
D. Administer IV fluids.
D. Administer IV fluids.
A nurse is preparing to start an IV infusion of LR for a client who sustained a burn injury, the client is prescribed 5,200ml of fluid over the first 24 hrs. How many ml/hr should the nurse set the pump to infuse for the first 8 hours?
325 ml/hr
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
A. Difficulty swallowing
B. Urinary output 25 mL/hr
C. Heart rate 122/min
D. Pain of 6 on a scale of 0 to 10
A. Difficulty swallowing
A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)
A. Blisters
B. Wound blanches with pressure
C. Dry face
D. Intact epidermis
E. Sensitive to touch
A. Blisters
B. Wound blanches with pressure
E. Sensitive to touch
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?
A. Weight loss
B. Oliguria
C. Hypernatremia
D. Increased thirst
B. Oliguria
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, “I feel so isolated and alone in this room”. After acknowledging the client’s feelings of loneliness, which of the following responses should the nurse provide?
a. I will come and sit with you for 10 minutes each hour.
b. Do you have a cell phone you can talk to friends and family on?
c. I’ll ask the charge nurse to admit someone to your room for company.
d. You’re scheduled for discharge in 2 days so this isolation will be over soon.
b. Do you have a cell phone you can talk to friends and family on?
A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be
A. Infertility
B. Diarrhea
C. Dysphagia
D. Dyspnea
C. Dysphagia
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
A. Anorexia and malnutrition
B. Diarrhea and dehydration
C. Bleeding from the gums
D. Full body alopecia
C. Bleeding from the gums
A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?
A. Delivering a child who has DS
B. Developing Alzheimers disease
C. Developing Breast Cancer
D. Developing thyroid cancer
C. Developing Breast Cancer
A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
A. Limit the number of health care workers entering the room.
B. Insert an indwelling catheter to monitor for sediment in the urine.
C. Take the client’s temperature once per shift
D. Provide the client with fresh fruit to avoid constipation
A. Limit the number of health care workers entering the room.
A nurse is caring for a client who is taking tamoxifen to treat breast cancer. The nurse should identify which of the following manifestations as an adverse effect of this medication?
A. Tinnitus
B. Hot flashes
C. Urinary frequency
D. Constipation
B. Hot flashes
A nurse at a provider’s office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply)
A. Add cream to soups
B. Dip meats in eggs and bread crumbs before cooking
C. Use milk instead of water in recipes
D. Top fruits with yogurt
E. Increase fluids during meals
A. Add cream to soups
B. Dip meats in eggs and bread crumbs before cooking
C. Use milk instead of water in recipes
D. Top fruits with yogurt
A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates a need for further teaching?
A. “I will drink liquids through a straw.”
B. “I will season foods with dried spices before cooking.”
C. “I will rinse my mouth with baking soda and water frequently.”
D. “I will eat frozen bananas as a snack.”
B. “I will season foods with dried spices before cooking.”
A nurse is providing teaching to a client who has cancer about foods that prevent protein energy malnutrition, which of the following foods should the nurse include?
cottage cheese
milkshakes
tuna fish
egg and ham omelette
A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include?
A. Walk outside in the early mornings.
B. Wash the irradiated area following treatment sessions to remove the markings.
C. Vigorously rub the skin dry after bathing
D. Keep the temperature in the home at least 33 C (91.4F).
A. Walk outside in the early mornings.
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?
A. Oral hypoglycemic medications
B. 0.9% sodium chloride IV bolus
C. Dextrose 5% in 0.45% sodium chloride
D. Glucocorticoid medications
B. 0.9% sodium chloride IV bolus
A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
A. “Withhold your usual daily dose of insulin.”
B. “Drink 240 to 360 milliliters of calorie-free liquids every 8 hours.”
C. “Test your blood glucose level every 8 hours.”
D. “Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.”
D. “Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.”
A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
a. Serum potassium level has increased.
b. Blood osmolarity has decreased.
c. Glasgow Coma Scale score is unchanged.
d. Urine remains negative for ketone
bodies.
c. Glasgow Coma Scale score is unchanged.
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?
a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
d. pH 7.32, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg
b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
