Quiz 6

Question 1

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

Answer 1

B. Airway obstruction

Question 2

Describe the rule of 9s

Answer 2

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 3

Question rule of 9s

Answer 3

31.5%

Question 4

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.

Answer 4

D. Inspect the mouth for signs of inhalation injuries.

Question 5

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

Answer 5

D. Location of the burn

Question 6

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.

Answer 6

D. Administer IV fluids.

Question 7

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?

Answer 7

325 ml/hr

Question 8

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

Answer 8

A. Difficulty swallowing

Question 9

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

Answer 9

A. Blisters
B. Wound blanches with pressure
E. Sensitive to touch

Question 10

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

Answer 10

B. Oliguria

Question 11

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.

Answer 11

b. Do you have a cell phone you can talk to friends and family on?

Question 12

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

Answer 12

C. Dysphagia

Question 13

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

Answer 13

C. Bleeding from the gums

Question 14

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

Answer 14

C. Developing Breast Cancer

Question 15

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

Answer 15

A. Limit the number of health care workers entering the room.

Question 16

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

Answer 16

B. Hot flashes

Question 17

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

Answer 17

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

Question 18

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.”

Answer 18

B. “I will season foods with dried spices before cooking.”

Question 19

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?

Answer 19

cottage cheese
milkshakes
tuna fish
egg and ham omelette

Question 20

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).

Answer 20

A. Walk outside in the early mornings.

Question 21

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

Answer 21

B. 0.9% sodium chloride IV bolus

Question 22

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.”

Answer 22

D. “Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.”

Question 23

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.

Answer 23

c. Glasgow Coma Scale score is unchanged.

Question 24

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

Answer 24

b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg

Question 25

In a client with diabetic ketoacidosis manifesting Kussmaul respirations, what is the nurse’s top priority action?

a. Administering oxygen by mask or nasal cannula
b. Administering intravenous 10% glucose
c. Implementing seizure precautions
d. Administering intravenous insulin

Answer 25

d. Administering intravenous insulin

Question 26

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. which of the following information should the nurse include?

a. women should start yearly mammograms at age 30
b. clients should have a colonoscopy at age 40 and every 10 years thereafter.
c. clients should have a yearly test for fecal occult blood.
d. women should have a yearly clinical breast examination starting at age 45.

Answer 26

c. clients should have a yearly test for fecal occult blood.

Question 27

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

a. An 18-year-old college student with type 1 diabetes who exercises excessively
b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Answer 27

d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Question 28

A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?

a. Blood pressure
b. Lung assessment
c. Oral mucous membranes
d. Skin integrity

Answer 28

a. Blood pressure

Question 29

Bowtie

Answer 29

Dx: pneumocystis jiroveci pneumonia

sulfa (septra)
sodium levels
liver enzymes
low platelet

Question 30

A nurse is caring for a client who has HIV infection dementia and has progressed
to AIDS. Which of the following findings should the nurse report?

Answer 30

night sweats

Question 31

Which type of cancer is associated with HIV disease?

a. Kaposi’s sarcoma
b. melanoma
c. lymphoma
d. renal cell carcinoma

Answer 31

a. Kaposi’s sarcoma

Question 32

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?

A. Auscultate cuff blood pressure.
B. Palpate pulse pressure.
C. Obtain a central venous pressure.
D. Monitor the pulmonary artery pressure.

Answer 32

D. Monitor the pulmonary artery pressure.

Question 33

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

a. The burned area is black in color and pain is absent.
b. The burned area is pink in color with blisters present.
c. The burned area is red in color with eschar present.
d. The burned area is yellow in color with severe edema.

Answer 33

c. The burned area is red in color with eschar present.

Question 34

A nurse is caring for a patient with SIADH with a creatinine of 1.3. Which of the following restrictions should you anticipate?

Answer 34

Fluid retention
Initiate fluid restriction - 1000 mL

Question 35

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?

a. Serum sodium 146 mEq/L
b. Blood glucose 80 mg/dL
c. Urine specific gravity 1.015
d. Blood urea nitrogen (BUN) 15 mg/dL

Answer 35

c. Urine specific gravity 1.015

Question 36

A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis?

Answer 36

tachycardia

Question 37

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following actions should the nurse take?

A. Restrict oral fluids to 800 to 1,000 mL/day.
B. Maintain an IV of 0.45% sodium chloride.
C. Ensure the client receives a 2 g/day sodium diet.
D. Administer desmopressin acetate 0.2 mg orally.

Answer 37

A. Restrict oral fluids to 800 to 1,000 mL/day.

Question 38

Patient chart case study question about 21 yr female with DKA

Answer 38

Increase IV rate and then consult with the PCP about the potassium prescription

Question 39

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?

a. Initiate Droplet Precautions for the client.
b. Notify the primary health care provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.

Answer 39

c. Place the client under Airborne Precautions.

Question 40

A client in the emergency department reports difficulty breathing. The nurse assesses the clients
appearance as depicted below:
What action by the nurse is the priority?

a. Assess blood pressure and pulse.
b. Attach the client to a pulse oximeter.
c. Have the client rate his or her pain.
d. Start high-dose steroid therapy.

Answer 40

a. Assess blood pressure and pulse.

Question 41

Admitting patient with HHS, what should the nurse question?

Answer 41

Administer ampule HCO3 IV STAT

Question 42

A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.)

a. Aspartate transaminase, alanine transaminase: elevated
b. CD4+ cell count: 180/mm3
c. Creatinine: 1.0 mg/dL
d. Platelet count: 80,000/mm3
e. Serum sodium: 120 mEq/L

Answer 42

a. Aspartate transaminase, alanine transaminase: elevated
d. Platelet count: 80,000/mm3
e. Serum sodium: 120 mEq/L