One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Explain the need for skin exposure to sunlight without sunscreen.

Teach the need for dietary and supplemental vitamin D.

Instruct the client in the use of muscle strengthening exercises.

Encourage progressive active range of motion.

Answer and Explanation

The Correct Answer is B

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

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Correct Answer is C

Explanation

Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.

Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.

Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.

Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.

A. An adult who is one day postoperative for a laparoscopic cholecystectomy. B. An older client who is one day postoperative with a colostomy for colon cancer. C. An older adult who is scheduled for foot amputation due to diabetes complications. D. An adult with alcoholism, cirrhosis, and hepatic encephalopathy.

Correct Answer is A

Explanation

Choice A reason: This client is relatively stable and the care required is within the scope of practice for a practical nurse (PN). Postoperative care for a laparoscopic cholecystectomy typically involves monitoring vital signs, pain management, and encouraging early ambulation, which the PN can perform with supervision.

Choice B reason: The older client with a colostomy for colon cancer may require more complex care and education about stoma management, which might be better suited for the RN.

Choice C reason: An older adult scheduled for foot amputation due to diabetes complications may have complex needs related to diabetes management and preoperative care, which require the RN's expertise.

Choice D reason: An adult with alcoholism, cirrhosis, and hepatic encephalopathy requires close monitoring for changes in mental status and liver function, which is more appropriate for the RN to manage.

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One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is C

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

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A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

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