A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Position the head of the bed flat.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore

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Correct Answer is D

Explanation

Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.

A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 22-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement. Which symptom should the nurse address first?

Correct Answer is D

Explanation

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. Which of the following manifestations should the nurse carefully monitor the client for?

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A nurse is attending to a client who has suffered a basal skull fracture. During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril. What should be the nurse’s immediate action?

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse consider when repositioning this patient?

A nurse is assisting in the care of a client who has developed cardiogenic shock. Which pulse site should the nurse use when assessing circulation to the client’s brain?

A nurse is assessing a client with a major burn injury. Which of the following findings should the nurse prioritize?