A nurse is contributing to the plan of care for a client who has partial-thickness and full-thickness burns on their lower extremities. Which of the following interventions should the nurse recommend including in the plan of care?

Administer filgrastim

Monitor the effects of dantrolene.

Initiate protective isolation

Wear a dosimeter when providing client care.

Answer and Explanation

The Correct Answer is C

A. Administer filgrastim: Filgrastim is used to stimulate white blood cell production in clients with neutropenia. It is not a standard intervention for burn patients unless they develop severe immunosuppression.

B. Monitor the effects of dantrolene: Dantrolene is indicated for malignant hyperthermia, not for burn management. Monitoring its effects is not relevant to the care of clients with partial- and full-thickness burns.

C. Initiate protective isolation: Clients with significant burns are at high risk for infection due to skin barrier loss. Protective isolation helps minimize exposure to pathogens, which is critical for preventing sepsis and promoting wound healing.

D. Wear a dosimeter when providing client care: Dosimeters are used to monitor exposure to ionizing radiation, which is not relevant in standard burn care. This intervention is unnecessary for routine burn management.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Notify the client's provider: Notifying the provider is important if there is concern for injury, but this should follow the initial assessment to determine the client’s condition. Immediate evaluation takes priority to identify any life-threatening or urgent issues.

B. Measure the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s hemodynamic status and identifies potential injuries or complications, such as internal bleeding or shock, following the fall. This guides subsequent interventions and provider notification.

C. Complete an incident report: Completing an incident report is necessary for legal and quality improvement purposes, but it is not the first priority. The client’s safety and clinical assessment take precedence over documentation.

D. Document the fall in the client's medical record: Accurate documentation is essential for continuity of care and legal reasons, but it should occur after assessing the client’s condition and initiating any necessary interventions.

A. Veracity B. Boundary crossing C. Countertransference D. Promoting trust

Correct Answer is D

Explanation

A. Veracity: Veracity refers to the ethical principle of being truthful with clients. While honesty is important in nursing, providing a meal to the client addresses their immediate physiological need rather than demonstrating truthfulness.

B. Boundary crossing: Boundary crossing occurs when a nurse engages in actions that deviate from professional limits, potentially for personal or emotional reasons. In this case, providing food to meet a basic client need does not constitute a boundary violation.

C. Countertransference: Countertransference happens when a nurse projects personal feelings onto a client, which can interfere with care. The nurse’s action here is intentional and focused on meeting the client’s needs, not influenced by personal unresolved emotions.

D. Promoting trust: Interrupting the bath to ensure the client receives nourishment demonstrates the nurse’s attentiveness, responsiveness, and prioritization of the client’s well-being. This action fosters a therapeutic relationship and builds trust between the nurse and client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is contributing to the plan of care for a client who has partial-thickness and full-thickness burns on their lower extremities. Which of the following interventions should the nurse recommend including in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to Implement?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following Instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?

The nurse reviews the client's test results. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL. IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is assisting with a prenatal examination of a client who is at weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?