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1 / 10
Category:
Medical-Surgical
The patient with burns is experiencing dehydration. Which of the following signs and symptoms indicate dehydration? Select all that apply.
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The correct answer is: Dehydration is characterized by elevated body temperature, tachycardia, tachypnea due to sympathetic nervous stimulation. Decreased urine output, dark concentrated urine and weight loss also occur. Fluid loss from the body will result to hypotension due to decrease in circulating volume.
2 / 10
Category:
Pharmacology
The client with hypertension in taking Atenolol (Tenormin). Nursing care of the client should include which of the following. Select all that apply.
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The correct answer is: Choice C is incorrect. Beta- blockers like Atenolol should be given on full stomach to prevent GI irritation.
3 / 10
Category:
Medical-Surgical
During the emergent phase of burns, which of the following assessment findings does the licensed nurse expect? Select all that apply.
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The correct answer is: The emergent phase of burns is also called shock phase or fluid accumulation phase. This occurs during the first 48 hours of burns. The fluid shifting is fromIVC to ISC due to vasodilation. This results from the heat and release of histamine in response to tissue injury.
4 / 10
Category:
Medical-Surgical
The patient has second degree burns from scalding from boiling water. Which of the following are characteristics of second degree burns? Select all that apply.
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The correct answer is: Second degree burns affect the epidermis and dermis; the area appears reddish, moist, with blisters or vesicles, it is painful, it is partial thickness burns.
5 / 10
Category:
Medical-Surgical
Which of the following findings indicate effective management of CHF. Select all that apply.
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The correct answer is: Effective management of CHF produce the following expected outcome: increased cardiac output, increased urine output, decreased weight, lowering of BP, may include stronger pulse, normal breath sounds.
Hypothyroidism Management
6 / 10
Category:
Medical-Surgical
Which of the following are expected manifestations of a patient with hypothyroidism. Select all that apply.
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The correct answer is: Hypothyroidism is characterized by hypometabolism, decreased body heat production and hypercalcemia (“Everything is low, slow and dry.”). Choices A, B and C are manifestations of hyperthyroidism.
7 / 10
Category:
Medical-Surgical
The patient has been diagnosed to have DM. Health teachings on foot care should include which of the following? Select all that apply.
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The correct answer is: Foot care is necessary in clients with DM to prevent gangrene formation. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice E is incorrect. Lotion, cream, powder should not be applied in spaces between the toes. These may cake and cause infection.
8 / 10
Category:
Medical-Surgical
A patient had burns of the right hand from boiling water. Which of the following nursing actions are appropriate when caring for this patient? Select all that apply.
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The correct answer is: To stop the burning process, the body part with burns should be immersed in cold water. Jewelries should be removed because metals can be superhead and will cause further tissue injury. Applying dressings on the fingers separately prevents contractures and adhesions. Splints should be applied with the fingers curbed to allow flexion and extension exercises of the fingers. This will also prevent hyperextension deformity of the fingers.
9 / 10
Category:
Medical-Surgical
The patient is experiencing metabolic alkalosis. Which of the following electrolyte imbalances may occur? Select all that apply.
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The correct answer is: Metabolic alkalosis leads to hypokalemia, hypocalcaemia and hyperphosphatemia. In alkalosis there is increased excretion of potassium, calcium is damaged. As calcium decreases, there is inverse hyperphosphatemia.
10 / 10
Category:
Medical-Surgical
The client experienced left CVA. Assessment findings include which of the following. Select all that apply.
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The correct answer is: Left homonymous hemianopsia, Right sided weakness and uncoordinated movements are manifestations of Left CVA. Choices C and D are manifestations of right CVA.
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