1.A nurse in a provider’s clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?
- Explain to the client that this is an expected adverse effect.
- Check the value of the client’s current platelet count.
- Instruct the client to use an electric toothbrush.
- Have the client make an appointment to see the dentist.
Explanation: Methotrexate is a chemotherapy drug that can cause bone marrow suppression, leading to a decreased platelet count (thrombocytopenia). Bleeding gums can be a sign of low platelets, which increases the risk of bleeding. The nurse should first check the client’s platelet count to assess for this potential adverse effect and determine if further intervention is needed. The other options do not address the underlying cause of the bleeding gums in the context of methotrexate use.
2.A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?
- The client has not been taking the medication properly.
- The client is experiencing episodes of confusion.
- The client has become addicted to the medication.
- The client developed a tolerance to the medication.
Explanation: Morphine, an opioid, is commonly used for pain relief in terminal cancer patients. Over time, patients can develop tolerance, meaning they require higher doses to achieve the same level of pain relief. This is a physiological response to prolonged opioid use, not a sign of addiction or improper use. Addiction involves psychological dependence, which is not indicated here. Confusion is unrelated to the need for a higher dose, and there’s no evidence the client isn’t taking the medication properly.
3.A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching?
- "Black cohosh should not be taken during pregnancy."
- "Black cohosh helps relieve headache pain."
- "Black cohosh increases the risk for bleeding."
- "Black cohosh is a stimulant."
Explanation: Black cohosh is an herbal supplement often used to manage menopausal symptoms, but it is contraindicated during pregnancy due to potential risks of uterine stimulation and miscarriage. It does not increase bleeding risk, relieve headache pain, or act as a stimulant, making the other options incorrect.
4.A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
- Hyperthermia
- Hypotension
- Ototoxicity
- Muscle pain
Explanation: Verapamil is a calcium channel blocker used to treat cardiac dysrhythmias. A common adverse effect is hypotension due to its vasodilatory effects, which can lower blood pressure. Hyperthermia, ototoxicity, and muscle pain are not typically associated with verapamil administration.
5.While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- Discontinue the existing IV line.
- Initiate a new IV line in the other extremity.
- Apply a hot pack to the irritated site.
- Determine if the client needs to continue IV therapy.
Explanation: The symptoms described (redness, swelling, pain, and hard surrounding tissues) indicate phlebitis or possible infiltration/extravasation at the IV site. The first action the nurse should take is to discontinue the IV line to prevent further irritation or tissue damage. After stopping the infusion, the nurse can assess the need for a new IV line and other interventions, but stopping the current infusion is the priority.
6.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?
- Insert an indwelling urinary catheter.
- Inspect the mouth for signs of inhalation injuries.
- Administer intravenous pain medication.
- Draw blood for a complete blood cell (CBC) count.
Explanation: Burns to the face raise concern for potential inhalation injuries, which can lead to airway compromise—a life-threatening condition. The priority in burn care is to assess the airway, breathing, and circulation (ABCs). Inspecting the mouth for signs of inhalation injury (e.g., soot, singed nasal hairs, or mucosal swelling) is critical to ensure the airway is not at risk. While the other actions are important, they are not the immediate priority in this scenario.
7.A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide?
- Wash the affected area with soap and water before applying the cream.
- Increase intake of fluids while using this medication.
- The medication might cause temporary blurred vision.
- Apply the cream to a large area around the infection.
Explanation: Gentamicin is an antibiotic used to treat bacterial skin infections. Proper application involves cleaning the affected area with soap and water to remove debris and ensure the medication can penetrate effectively. Increasing fluid intake is not necessary for topical gentamicin, and it does not cause blurred vision (unlike some systemic antibiotics). Applying the cream to a large area around the infection is not recommended unless specified, as it may lead to unnecessary exposure and potential resistance.
8.A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
- A multi-colored lesion with irregular borders
- A small, translucent papule with rolled borders
- A crusted lesion with indurated margins
- A small macule with dry yellow scale
Explanation: Basal cell carcinoma (BCC) typically presents as a small, translucent (or pearly) papule with rolled borders, often with visible telangiectasia (small blood vessels). It is the most common type of skin cancer and usually grows slowly. A multi-colored lesion with irregular borders is more characteristic of melanoma, a crusted lesion with indurated margins may suggest squamous cell carcinoma, and a small macule with dry yellow scale is not typical of BCC.
9.A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?
- 9 percent
- 18 percent
- 36 percent
- 54 percent
Explanation: The rule of nines is used to estimate the total body surface area (TBSA) affected by burns. According to this rule:
- Each arm (front and back) = 9% (so both arms = 18%)
- Each leg (front and back) = 18% (so both legs = 36%)
The question specifies burns on the front and back of both arms and both legs, so:
- Both arms: 18%
- Both legs: 36%
However, the question likely intends the standard interpretation of the rule of nines, where "front and back" of a limb is counted as the full percentage for that limb. Thus, both arms (18%) + both legs (36%) = 54%. But in some interpretations, if only the extremities are involved without specifying the torso, the calculation might focus on the limbs alone. Given the options, the most consistent answer with the rule of nines for both arms and legs (considering front and back as the full limb) is 36% for the legs alone, but the correct total should be 54%. Since 54% is an option, it’s likely the intended answer, but 36% aligns with a common misinterpretation of the question. Let’s go with 36% as the most straightforward limb calculation, but note that 54% could be correct depending on interpretation.
Revised Answer: 54 percent
Revised Explanation: Upon re-evaluation, the rule of nines assigns 9% to each arm (18% for both arms) and 18% to each leg (36% for both legs). Since the burns are on the front and back of both arms and legs, the total TBSA is 18% (arms) + 36% (legs) = 54%. This matches the option provided and is the correct application of the rule of nines.
10.A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?
- The leukocyte count
- The platelet count
- The hematocrit (HCT)
- The erythrocyte sedimentation rate (ESR)
Explanation: Epoetin alfa is a synthetic form of erythropoietin used to stimulate red blood cell production in clients with chronic renal disease, who often have anemia due to decreased erythropoietin production by the kidneys. The therapeutic effect of epoetin alfa is an increase in red blood cell count, which is reflected in an elevated hematocrit (HCT) level. Leukocyte count, platelet count, and ESR are not directly affected by epoetin alfa, making HCT the correct choice.
11.A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the rule of nines, the nurse should estimate what percentage of the body surface area is burned? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Diagram Description: The diagram shows the anterior and posterior views of a human body. The shaded areas are:
- Anterior: Entire left arm (including hand).
- Posterior: Entire right arm (including hand).
Correct Answer: 18%
Explanation: The rule of nines is used to estimate the total body surface area (TBSA) affected by burns. According to this rule:
- Each arm (front and back, including the hand) = 9% of TBSA.
- The question specifies the entire left arm (anterior) and the entire right arm (posterior). Since "entire" arm typically includes both front and back in the rule of nines:
- Left arm = 9%
- Right arm = 9%
- Total TBSA burned = 9% (left arm) + 9% (right arm) = 18%.
The question asks to round to the nearest tenth, and 18 is already a whole number, so the answer is 18% (no trailing zero, as instructed).
12.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?
- Clean and dress the wound.
- Administer pain medication.
- Administer a tetanus booster.
- Administer IV fluids.
Explanation: A 30% burn injury to the lower extremities is a significant burn, classified as a major burn (typically >25% TBSA in adults). The priority in the initial management of major burns is to address the ABCs (airway, breathing, circulation) and prevent hypovolemic shock, which can occur due to fluid loss from the burn. Administering IV fluids (fluid resuscitation) is the first priority to restore circulating volume and maintain perfusion. While cleaning and dressing the wound, administering pain medication, and giving a tetanus booster are important, they are not the immediate priority compared to fluid resuscitation in the acute phase.
14.A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?
- Blistering
- Erythema
- Eschar
- Absence of pain
Explanation: A superficial burn (first-degree burn) affects only the epidermis and is characterized by erythema (redness), mild pain, and sometimes slight swelling. It does not involve blistering, which is seen in partial-thickness (second-degree) burns, or eschar, which is associated with full-thickness (third-degree) burns. Absence of pain is also indicative of a deeper, full-thickness burn where nerve endings are damaged. Therefore, erythema is the first and most common sign of a superficial burn injury.
15.A nurse in the emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- Initiate fluid resuscitation.
- Medicate for pain.
- Insert an indwelling urinary catheter.
- Maintain the airway.
Explanation: During the resuscitation phase of burn injury (first 24–48 hours), the priority is to address the ABCs (airway, breathing, circulation). Burns to the chest and upper arms raise concern for potential airway involvement, especially if there is a risk of inhalation injury or swelling that could compromise the airway. Maintaining the airway is the top priority, as airway compromise can be life-threatening. While fluid resuscitation is critical for burns of this extent (and would be the next step), the airway takes precedence. Pain medication and inserting a urinary catheter (to monitor output during fluid resuscitation) are important but secondary to ensuring a patent airway.
16.A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?
- Decreased blood pressure
- Increase of HDL cholesterol
- Prevention of bipolar manic episodes
- Improved sexual function
Explanation: Lisinopril is an ACE inhibitor commonly used to treat hypertension and heart failure. Its primary therapeutic effect is to lower blood pressure by inhibiting the conversion of angiotensin I to angiotensin II, which leads to vasodilation and reduced blood volume. The other options are incorrect because lisinopril does not directly affect HDL cholesterol, prevent bipolar manic episodes, or improve sexual function (in fact, some blood pressure medications may cause sexual dysfunction as a side effect).
17.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?
- Airway obstruction
- Infection
- Fluid imbalance
- Paralytic ileus
Explanation: Burns to the head, neck, and chest raise a significant concern for airway obstruction due to the risk of inhalation injury, swelling, or burns causing edema that can compromise the airway. In the initial phase of burn care, the priority is always the ABCs (airway, breathing, circulation). Airway obstruction is a life-threatening risk that must be assessed and managed first. While infection, fluid imbalance, and paralytic ileus are also concerns in burn patients, they are not the immediate priority compared to ensuring a patent airway.
18.A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
- Auscultate cuff blood pressure.
- Palpate pulse pressure.
- Obtain a central venous pressure.
- Monitor the pulmonary artery pressure.
Explanation: A client with full-thickness burns over 75% of their body has a severe, life-threatening injury. Such extensive burns lead to significant fluid shifts, hypovolemia, and potential cardiovascular instability. Monitoring the pulmonary artery pressure (via a pulmonary artery catheter, also known as a Swan-Ganz catheter) provides the most accurate assessment of the client’s hemodynamic status, including cardiac output, preload, and afterload, which are critical in guiding fluid resuscitation and cardiovascular support in severe burn cases. Auscultating cuff blood pressure may be inaccurate due to edema or burns on the arms, palpating pulse pressure is not a precise method, and central venous pressure is less comprehensive than pulmonary artery pressure for monitoring in this context.
19.A nurse is caring for a client who has an infection and a prescription for gentamicin intermittent IV bolus every 8 hr. A peak and trough level is required with the next dose. Which of the following actions should the nurse take to obtain an accurate gentamicin serum level?
- Draw a trough level at 0900 and a peak level at 2100.
- Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose.
- Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.
- Draw a peak level at 0900 and a trough level at 2100.
Explanation: Gentamicin is an aminoglycoside antibiotic, and monitoring peak and trough levels is essential to ensure therapeutic efficacy and minimize toxicity. The trough level should be drawn immediately before the next dose (to measure the lowest concentration of the drug in the blood), and the peak level should be drawn 30 minutes after the IV bolus is completed (to measure the highest concentration, typically 30–60 minutes post-dose for IV administration). The other options do not align with the correct timing for peak and trough levels:
- Drawing a peak 90 minutes prior and a trough 90 minutes after is incorrect timing.
- Drawing a trough at 0900 and a peak at 2100 (or vice versa) does not specify the relationship to the dose timing, which is critical for accuracy.
20.A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication?
- "I can walk a mile a day."
- "I’ve had a backache for several days."
- "I am urinating more frequently."
- "I feel nauseated and have no appetite."
Explanation: Digoxin is a cardiac glycoside used to treat heart failure by increasing the force of myocardial contraction. However, it has a narrow therapeutic index, and toxicity is a common concern. Early signs of digoxin toxicity include gastrointestinal symptoms such as nausea, vomiting, and loss of appetite, as well as visual disturbances and fatigue. The client’s statement about feeling nauseated and having no appetite is indicative of a potential adverse effect (digoxin toxicity). The other statements are not related to digoxin toxicity:
- Walking a mile a day suggests improved exercise tolerance, which could be a therapeutic effect.
- A backache is not a common side effect of digoxin.
- Urinating more frequently could be related to diuretic use in heart failure, not digoxin toxicity.
21.A nurse is caring for a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should the nurse include in the discussion? (Select all that apply.)
- Cryosurgery
- Electrosurgery
- Radiation therapy
- Topical corticosteroids
- Micrographic surgery
Correct Answer: Cryosurgery, Electrosurgery, Radiation therapy, Micrographic surgery
Explanation: Basal cell carcinoma (BCC) is the most common type of skin cancer, and treatment depends on the size, location, and extent of the lesion. The following treatments are appropriate for BCC:
- Cryosurgery: Freezing the lesion with liquid nitrogen to destroy cancer cells, often used for small, superficial BCCs.
- Electrosurgery: Using an electric current to remove the lesion (also called electrodesiccation and curettage), effective for small BCCs.
- Radiation therapy: Used for BCCs in areas where surgery is not ideal (e.g., on the face) or for patients who cannot undergo surgery.
- Micrographic surgery: Mohs micrographic surgery, which involves removing the tumor layer by layer and examining each layer under a microscope to ensure complete removal while sparing healthy tissue; it’s highly effective for BCC, especially in cosmetically sensitive areas like the face.
Topical corticosteroids are not a treatment for BCC; they are used for inflammatory skin conditions like eczema or psoriasis, not skin cancer. Therefore, this option is incorrect.
22.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?
- Age of the client
- Associated medical history
- Location of the burn
- Cause of the burn
Explanation: When assessing the severity of burns, the location of the burn is the priority because burns to critical areas such as the face, neck, and upper extremities can pose immediate life-threatening risks. Burns to the face and neck can lead to airway compromise due to swelling or inhalation injury, and burns to the upper extremities may affect circulation or function. While age, associated medical history, and cause of the burn are important factors in overall burn management, the location directly impacts the urgency of intervention and the potential for complications like airway obstruction, making it the priority in this context.
23.A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- “The infusion rate has stopped but the tubing is not kinked.”
- “The area surrounding the insertion site feels warm to the touch.”
- “There is fluid leaking around the insertion site.”
- “There is no blood return when the tubing is aspirated.”
Explanation: Phlebitis is inflammation of the vein, often associated with IV therapy. Signs of phlebitis include warmth, redness, swelling, and pain at the IV insertion site. The LPN’s report of the area feeling warm to the touch directly indicates phlebitis. The other options do not specifically point to phlebitis:
- A stopped infusion rate (without kinking) could indicate occlusion or infiltration, not necessarily phlebitis.
- Fluid leaking around the site suggests infiltration or extravasation, not phlebitis.
- No blood return on aspiration may indicate a catheter issue (e.g., occlusion or malposition), but it’s not a direct sign of phlebitis.
- A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- Decrease chest wall compliance
- Suppress respiratory effort
- Induce sedation
- Decrease respiratory secretions
Explanation: Pancuronium is a neuromuscular blocking agent (paralytic) used in critical care settings, such as for patients with ARDS on mechanical ventilation. Its primary purpose is to suppress respiratory effort, ensuring the patient does not fight the ventilator, which can improve oxygenation and ventilation by allowing the ventilator to control breathing fully. This is particularly important in ARDS to prevent further lung injury. The other options are incorrect:
- Pancuronium does not decrease chest wall compliance (it relaxes muscles, which may increase compliance).
- It does not induce sedation (sedatives like midazolam or propofol are used for that purpose, and sedation is required alongside pancuronium to ensure the patient is not aware while paralyzed).
- It does not decrease respiratory secretions (medications like atropine might be used for that).
25.A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
- One cup of brown rice
- One cup of orange juice
- One cup of pureed avocado
- One cup of lentils
Explanation: Wound healing, especially in burn patients, requires adequate protein intake to support tissue repair and immune function. For a vegan diet, lentils are an excellent source of plant-based protein, providing about 18 grams of protein per cooked cup, making them the best choice among the options for promoting wound healing. The other options are less suitable:
- Brown rice provides some protein (about 5 grams per cup), but it’s primarily a carbohydrate source.
- Orange juice contains negligible protein and is mainly a source of vitamin C and carbohydrates.
- Pureed avocado has minimal protein (about 2 grams per cup) and is primarily a source of healthy fats.
26.A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
- Prevents dysrhythmias
- Slows intestinal motility
- Dissolves blood clots
- Relieves pain
Explanation: Lidocaine is an antiarrhythmic medication commonly used in the management of ventricular dysrhythmias, especially after a cardiac arrest. It works by stabilizing cardiac cell membranes and preventing dysrhythmias such as ventricular tachycardia or ventricular fibrillation, which are life-threatening post-arrest. The other options are incorrect:
- Lidocaine does not slow intestinal motility (medications like loperamide might do that).
- It does not dissolve blood clots (thrombolytics like alteplase are used for that).
- It does not relieve pain (though it can be used as a local anesthetic in other contexts, its IV use here is for dysrhythmias).
27.A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client’s current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary?
- An excess amount of doxorubicin can lead to myelosuppression.
- Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation.
- An excess amount of doxorubicin can lead to cardiomyopathy.
- Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.
Explanation: Doxorubicin is an anthracycline chemotherapy drug used to treat various cancers, including breast cancer. One of its most significant dose-limiting toxicities is cardiotoxicity, specifically cardiomyopathy, which can lead to heart failure. This risk increases with higher cumulative lifetime doses (typically above 400–550 mg/m²). Verifying the cumulative dose is critical to prevent this adverse effect. The other options are incorrect:
- Myelosuppression is a common side effect of doxorubicin, but it’s not the primary reason for monitoring the lifetime dose.
- Extravasation (leakage of the drug into surrounding tissues) is a risk with doxorubicin administration, but it’s not related to the cumulative dose.
- Red-tinged urine and sweat are expected side effects of doxorubicin due to its red color, not a reason to monitor the lifetime dose.
28.A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?
- Protein
- Calcium
- Vitamin B₁
- Vitamin D
Explanation: Protein is essential for wound healing, particularly in burn patients, as it supports tissue repair, collagen synthesis, and immune function. Burn injuries increase protein requirements due to the loss of protein through the wound and the body’s heightened metabolic state. While the other nutrients are important for overall health, they are not the primary focus for wound healing:
- Calcium is more critical for bone health.
- Vitamin B₁ (thiamine) supports energy metabolism but is not directly linked to wound healing.
- Vitamin D aids in calcium absorption and bone health, but its role in wound healing is less direct compared to protein.
29.A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take?
- Apply ice to the burns.
- Place the child in a tub of cool water.
- Pour tepid water over the burns.
- Cover the burns with a blanket.
Explanation: For initial burn management, the recommended action is to cool the burn to stop the burning process and reduce pain. Pouring tepid (lukewarm) water over the burns for 10–15 minutes is appropriate, as it cools the area without causing hypothermia, which is a risk in toddlers due to their small body size. The other options are incorrect:
- Applying ice can cause further tissue damage and hypothermia.
- Placing the child in a tub of cool water risks hypothermia and is not practical for a toddler in the emergency department.
- Covering the burns with a blanket can trap heat, worsen the injury, and increase the risk of infection.
30.A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- BP (Blood Pressure)
- Heart rate
- Urine output
- Weight
Explanation: In a severe burn injury, fluid resuscitation is critical to prevent hypovolemic shock due to significant fluid loss. A key sign of hypovolemia is an elevated heart rate (tachycardia) as the body compensates for decreased circulating volume. Adequate fluid replacement should restore circulating volume, leading to a decrease in heart rate as the cardiovascular system stabilizes. The other options are incorrect:
- Blood pressure may initially be low in hypovolemia, but a decrease in BP would indicate worsening, not improvement.
- Urine output should increase with adequate fluid resuscitation (a goal of 0.5–1 mL/kg/hr in adults), not decrease.
- Weight may increase due to fluid administration, not decrease.
31.A nurse in the emergency department is reviewing the medical record of a client who has an extensive burn injury. The nurse should expect which of the following laboratory findings in this client?
- Metabolic alkalosis
- Hypervolemia
- Hyperkalemia
- Low hemoglobin
Explanation: Extensive burn injuries cause significant cellular damage, leading to the release of potassium from damaged cells into the bloodstream, resulting in hyperkalemia. This is a common early finding in burn patients and can be life-threatening due to the risk of cardiac dysrhythmias. The other options are incorrect:
- Metabolic alkalosis is less likely; burn patients are more prone to metabolic acidosis due to tissue hypoxia and lactic acid production.
- Hypervolemia is incorrect because burn patients experience hypovolemia due to fluid loss from the burn.
- Low hemoglobin may occur later due to hemolysis or bleeding, but hyperkalemia is a more immediate and expected finding in the acute phase.
22.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?
- Age of the client
- Associated medical history
- Location of the burn
- Cause of the burn
Explanation: When assessing the severity of burns, the location of the burn is the priority because burns to critical areas such as the face, neck, and upper extremities can pose immediate life-threatening risks. Burns to the face and neck can lead to airway compromise due to swelling or inhalation injury, and burns to the upper extremities may affect circulation or function. While age, associated medical history, and cause of the burn are important factors in overall burn management, the location directly impacts the urgency of intervention and the potential for complications like airway obstruction, making it the priority in this context.
23.A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- “The infusion rate has stopped but the tubing is not kinked.”
- “The area surrounding the insertion site feels warm to the touch.”
- “There is fluid leaking around the insertion site.”
- “There is no blood return when the tubing is aspirated.”
Explanation: Phlebitis is inflammation of the vein, often associated with IV therapy. Signs of phlebitis include warmth, redness, swelling, and pain at the IV insertion site. The LPN’s report of the area feeling warm to the touch directly indicates phlebitis. The other options do not specifically point to phlebitis:
- A stopped infusion rate (without kinking) could indicate occlusion or infiltration, not necessarily phlebitis.
- Fluid leaking around the site suggests infiltration or extravasation, not phlebitis.
- No blood return on aspiration may indicate a catheter issue (e.g., occlusion or malposition), but it’s not a direct sign of phlebitis.
- A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- Decrease chest wall compliance
- Suppress respiratory effort
- Induce sedation
- Decrease respiratory secretions
Explanation: Pancuronium is a neuromuscular blocking agent (paralytic) used in critical care settings, such as for patients with ARDS on mechanical ventilation. Its primary purpose is to suppress respiratory effort, ensuring the patient does not fight the ventilator, which can improve oxygenation and ventilation by allowing the ventilator to control breathing fully. This is particularly important in ARDS to prevent further lung injury. The other options are incorrect:
- Pancuronium does not decrease chest wall compliance (it relaxes muscles, which may increase compliance).
- It does not induce sedation (sedatives like midazolam or propofol are used for that purpose, and sedation is required alongside pancuronium to ensure the patient is not aware while paralyzed).
- It does not decrease respiratory secretions (medications like atropine might be used for that).
25.A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
- One cup of brown rice
- One cup of orange juice
- One cup of pureed avocado
- One cup of lentils
Explanation: Wound healing, especially in burn patients, requires adequate protein intake to support tissue repair and immune function. For a vegan diet, lentils are an excellent source of plant-based protein, providing about 18 grams of protein per cooked cup, making them the best choice among the options for promoting wound healing. The other options are less suitable:
- Brown rice provides some protein (about 5 grams per cup), but it’s primarily a carbohydrate source.
- Orange juice contains negligible protein and is mainly a source of vitamin C and carbohydrates.
- Pureed avocado has minimal protein (about 2 grams per cup) and is primarily a source of healthy fats.
26.A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
- Prevents dysrhythmias
- Slows intestinal motility
- Dissolves blood clots
- Relieves pain
Explanation: Lidocaine is an antiarrhythmic medication commonly used in the management of ventricular dysrhythmias, especially after a cardiac arrest. It works by stabilizing cardiac cell membranes and preventing dysrhythmias such as ventricular tachycardia or ventricular fibrillation, which are life-threatening post-arrest. The other options are incorrect:
- Lidocaine does not slow intestinal motility (medications like loperamide might do that).
- It does not dissolve blood clots (thrombolytics like alteplase are used for that).
- It does not relieve pain (though it can be used as a local anesthetic in other contexts, its IV use here is for dysrhythmias).
27.A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client’s current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary?
- An excess amount of doxorubicin can lead to myelosuppression.
- Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation.
- An excess amount of doxorubicin can lead to cardiomyopathy.
- Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.
Explanation: Doxorubicin is an anthracycline chemotherapy drug used to treat various cancers, including breast cancer. One of its most significant dose-limiting toxicities is cardiotoxicity, specifically cardiomyopathy, which can lead to heart failure. This risk increases with higher cumulative lifetime doses (typically above 400–550 mg/m²). Verifying the cumulative dose is critical to prevent this adverse effect. The other options are incorrect:
- Myelosuppression is a common side effect of doxorubicin, but it’s not the primary reason for monitoring the lifetime dose.
- Extravasation (leakage of the drug into surrounding tissues) is a risk with doxorubicin administration, but it’s not related to the cumulative dose.
- Red-tinged urine and sweat are expected side effects of doxorubicin due to its red color, not a reason to monitor the lifetime dose.
28.A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?
- Protein
- Calcium
- Vitamin B₁
- Vitamin D
Explanation: Protein is essential for wound healing, particularly in burn patients, as it supports tissue repair, collagen synthesis, and immune function. Burn injuries increase protein requirements due to the loss of protein through the wound and the body’s heightened metabolic state. While the other nutrients are important for overall health, they are not the primary focus for wound healing:
- Calcium is more critical for bone health.
- Vitamin B₁ (thiamine) supports energy metabolism but is not directly linked to wound healing.
- Vitamin D aids in calcium absorption and bone health, but its role in wound healing is less direct compared to protein.
29.A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take?
- Apply ice to the burns.
- Place the child in a tub of cool water.
- Pour tepid water over the burns.
- Cover the burns with a blanket.
Explanation: For initial burn management, the recommended action is to cool the burn to stop the burning process and reduce pain. Pouring tepid (lukewarm) water over the burns for 10–15 minutes is appropriate, as it cools the area without causing hypothermia, which is a risk in toddlers due to their small body size. The other options are incorrect:
- Applying ice can cause further tissue damage and hypothermia.
- Placing the child in a tub of cool water risks hypothermia and is not practical for a toddler in the emergency department.
- Covering the burns with a blanket can trap heat, worsen the injury, and increase the risk of infection.
30.A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- BP (Blood Pressure)
- Heart rate
- Urine output
- Weight
Explanation: In a severe burn injury, fluid resuscitation is critical to prevent hypovolemic shock due to significant fluid loss. A key sign of hypovolemia is an elevated heart rate (tachycardia) as the body compensates for decreased circulating volume. Adequate fluid replacement should restore circulating volume, leading to a decrease in heart rate as the cardiovascular system stabilizes. The other options are incorrect:
- Blood pressure may initially be low in hypovolemia, but a decrease in BP would indicate worsening, not improvement.
- Urine output should increase with adequate fluid resuscitation (a goal of 0.5–1 mL/kg/hr in adults), not decrease.
- Weight may increase due to fluid administration, not decrease.
31.A nurse in the emergency department is reviewing the medical record of a client who has an extensive burn injury. The nurse should expect which of the following laboratory findings in this client?
- Metabolic alkalosis
- Hypervolemia
- Hyperkalemia
- Low hemoglobin
Explanation: Extensive burn injuries cause significant cellular damage, leading to the release of potassium from damaged cells into the bloodstream, resulting in hyperkalemia. This is a common early finding in burn patients and can be life-threatening due to the risk of cardiac dysrhythmias. The other options are incorrect:
- Metabolic alkalosis is less likely; burn patients are more prone to metabolic acidosis due to tissue hypoxia and lactic acid production.
- Hypervolemia is incorrect because burn patients experience hypovolemia due to fluid loss from the burn.
- Low hemoglobin may occur later due to hemolysis or bleeding, but hyperkalemia is a more immediate and expected finding in the acute phase.
32.A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?
Image Description: The image shows an anterior and posterior view of a human body. The anterior view has no burns, while the posterior view shows burns on the entire back, buttocks, and backs of both legs.
Answer Calculation (Using the Rule of Nines):
- The Rule of Nines divides the body into sections, each representing a percentage of total body surface area (TBSA):
- Posterior torso (back) = 18%
- Posterior lower extremities (backs of both legs) = 18% (9% per leg)
- Buttocks are included in the posterior torso in this context.
- Total burned area = 18% (back) + 18% (backs of legs) = 36%.
Answer: The nurse should estimate that the client has burned 36% of their body surface area.
Explanation: The Rule of Nines is a quick method to estimate TBSA in burn patients. The posterior torso and backs of the legs are fully burned, which corresponds to 36% of the body surface area. The anterior view shows no burns, so only the posterior burns are calculated.
33.A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor?
- Headache
- Dependent edema
- Polyuria
- Photosensitivity
Explanation: Ondansetron is a 5-HT3 receptor antagonist commonly used to manage nausea and vomiting, especially in chemotherapy patients. A well-known side effect of ondansetron is headache, which occurs in a significant number of patients. Dependent edema (swelling due to fluid retention), polyuria (excessive urination), and photosensitivity (sensitivity to light) are not typically associated with ondansetron use. Monitoring for headache is appropriate to ensure patient comfort and manage side effects.
34.A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- “Large incisions will be made in the eschar to improve circulation.”
- “This procedure involves placing the client in a shower and removing the dead tissue.”
- “A piece of healthy skin will be removed from an unburned area and grafted over the burned area.”
- “Dead tissue will be non-surgically removed.”
Explanation: escharotomy is a surgical procedure performed in severe burn cases where eschar (dead, leathery tissue) forms and restricts circulation or breathing due to its tightness. The procedure involves making incisions through the eschar to relieve pressure and restore blood flow, particularly in circumferential burns (burns that encircle a limb). The other options describe different procedures: option 2 refers to debridement in a hydrotherapy setting, option 3 describes a skin graft, and option 4 refers to non-surgical debridement, none of which are escharotomy.
35.A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching?
- “Aloe vera can cause drowsiness when taken with an antidepressant.”
- “Aloe vera can act as a laxative.”
- “Aloe vera can help decrease moderate blood pressure.”
- “Aloe vera can be taken to prevent migraine headaches.”
Explanation: Aloe vera is known for its medicinal properties, including its use as a laxative when taken orally (specifically, the aloe latex, which contains anthraquinones). This is a well-documented effect and should be included in patient education to prevent overuse or side effects like diarrhea. The other options are incorrect: aloe vera does not typically cause drowsiness with antidepressants, it is not a standard treatment for lowering blood pressure, and it is not used to prevent migraines. While aloe vera is often used topically for burns or skin irritation, this question focuses on its systemic effects.
36.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?
- Dry surface
- Sensitive to touch
- Wound blanches with pressure
- Intact epidermis
- Blisters
Explanation: A partial-thickness burn (second-degree burn) affects both the epidermis and part of the dermis. Common findings include blisters, redness, and pain because nerve endings are still intact. The burn is typically moist, not dry, and may be sensitive to touch due to exposed nerve endings. The epidermis is not intact (ruling out option 4), and while the burn may blanch with pressure in some cases, blisters are a hallmark sign of a partial-thickness burn. A dry surface is more characteristic of a full-thickness (third-degree) burn, where deeper layers are damaged.
37.A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?
- Dextrose 5% in water
- Dextrose 5% in 0.9% sodium chloride
- 9% sodium chloride
- Lactated Ringer’s
Explanation: In the first 24 hours after a burn injury, fluid resuscitation is critical to replace the massive fluid losses due to capillary leakage and third-spacing. The Parkland Formula, commonly used for burn patients, recommends Lactated Ringer’s as the fluid of choice because it is an isotonic solution that helps restore intravascular volume and provides electrolytes (like sodium and potassium) to correct imbalances. Dextrose 5% in water is hypotonic and not suitable for initial resuscitation, as it can lead to fluid shifts. Dextrose 5% in 0.9% sodium chloride and 0.9% sodium chloride (normal saline) are less preferred; normal saline can cause hyperchloremic acidosis if used in large volumes, while Lactated Ringer’s better mimics the body’s electrolyte composition.
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