Comprehensive Quiz SITUATION: the client 65 y/o has been experiencing cramping pain in her lower abdomen and has noticed a gradual change in her elimination pattern. She is admitted to the hospital for a diagnostic workup and probable surgery

1.) The client is scheduled for barium enema. Preparation includes administration of 60ml of castor oil orally. Castor oil facilitates cleansing of the bowel primarily by:A.) softening of fecesB.) Lubricating the stoolC.) Increasing the volume of intestinal contentD.) Irritating the nerve endings in the intestinal mucosa

Ans: D

2.) Following barium enema, the nurse should be prepared to administer which type of medication?A.) LaxativeB.) AntiemeticC.) AntacidD.) antibiotic

Ans: A

3.) The diagnosis of cancer is confirmed. The client is scheduled for permanent colostomy. The preferred site would be:A.) Ascending colonB.) Lower portion of the descending colonC.) Middle portion of the transverse colonD.) Ileum

Ans: B

4.) The patient had NGT inserted at the time of surgery. The tube will most likely be removed when the client demonstratesA.) Absence of bowel soundsB.) Passage of mucus from the rectumC.) Passage of flatus and feces from the colostomyD.) Absence of gastric drainage for about 24hours

Ans: C

5.) A colostomy irrigation is ordered on the 5th postop day. The primary purpose of this first

irrigation is to:A.) Cleanse the colonB.) Regulate the bowelC.) Dilate the sphincterD.) Stimulate peristalsis

Ans: D

6.) Which of the following preparations would be best to apply around the colostomy?A.) KarayaB.) PetroleumC.) CornstarchD.) Antiseptic cream

Ans: A

SITUATION: Mr. H. Sy, 51 y/o is admitted with a diagnosis of end-stage, irreversible chronic renal failure. He has been scheduled for hemodialysis. He has an A-V fistula created in his left forearm.

7.) Mr. Sy, is being given aluminum hydroxide gel (Amphogel) 40 ml. after meals and at bedtime. The primary purpose of prescribing this medication is to:A.) Relieve gastric irritationB.) Prevent metabolic acidosisC.) Prevent peptic ulcer formationD.) Phosphate levels lower serum

Ans: D

8.) The nursing care plan states to observe for hyperkalemia. The nurse should recognize that the greatest risk of hyperkalemia is:A.) TetanyB.) Cardiac arrestC.) Fluid overloadD.) Internal bleeding

Ans: B

9.) The physician orders sodium polysterene sulfonate 15g (exchange resin kayexalate) four times a day. The expected outcome of this medication is to:A.) Lower serum potassiumB.) Lower BPC.) Increase urinary outputD.) Prevent hemorrhage

Ans: A

10.) The physician orders regular insulin, 10 U added to 50 ml of 50% dextrose to be given

intravenously. The expected outcome is to:A.) Lower the blood sugarB.) Decrease the serum potassiumC.) Reduce cerebral edemaD.) Prevent tetany

Ans: B

11.) While caring for Mr. Sy who is now having hemodialysis via A-V shunt, the nurse should recognize that:A.) The use of stethoscope to auscultate the fistula is contraindicatedB.) The client feels best immediately after the hemodialysisC.) Taking BP on the affected arm can cause clottingD.) No pain should be experienced during initiation of the dialysis

Ans: C

12.) Following hemodialysis, the nurse should anticipateA.) weight lossB.) PolyuriaC.) Increased BPD.) Glycosuria

Ans: A

13.) After hemodialysis, the expected outcome is decreased serumA.) BicarbonateB.) CreatinineC.) ProteinsD.) Glucose

Ans: B

14.) The nurse observe symptoms of disequilibrium syndrome which includesA.) Headache, confusion, and seizureB.) Ankle edema, rales, weight gainC.) Fever, joint pain and chillsD.) Decreased BP, tachycardia and chest pain

Ans: A

15.) Which of the following blood values will not be improved by hemodialysis?A.) Elevated serum creatinineB.) HyperkalemiaC.) Low hemoglobinD.) Hypernatremia

Ans: C

16.) Signs and symptoms of ECF volume excess include the following EXCEPT:A.) Weight gainB.) Tight, smooth shiny skinC.) Puffy eyelidsD.) Flushed, dry skin

Ans: D

17.) The following are manifestations of dehydration EXCEPT:A.) ThirstB.) Diluted urine and polyuriaC.) Weight lossD.) Poor skin turgor

Ans: B

Situation: Mike’s history was taken upon admission. Impression is peptic ulcer disease (P.U.D.)

18.) Mike was prescribed antacids. The rationale for prescribing antacids to Mike is to:A.) Decrease gastric motilityB.) Neutralize gastric acidC.) Aid in the digestion processD.) Prevent constipation

Ans: B

19.) The nurse recognizes that the diet best indicated and must be prescribed for Mike is:A.) Bland dietB.) Full DietC.) Sippy dietD.) Karrel’s diet

Ans: A

SITUATION: Mr. M is a 35 y/o bus driver. Accidentally, he sustained second and third degree burns of the chest, anterior portion of both arms and anterior and posterior portions of his right leg.

20.) At the scene of the accident, the burning process may be stopped by:A.) Immersing the burned parts in cold waterB.) Applying oil to the burned partsC.) Flushing the burned areas with a weak solution of vinegarD.) Covering the burned areas with dry, sterile dressings

Ans: A

21.) Based on the rule of 9’s, which percentage is the best estimate of the extent of the client’s burns?A.) 36B.) 27C.) 26D.) 46

Ans: A

22.) Deep partial thickness burns (2nd degree) involves the:A.) Epidermis onlyB.) Entire epidermis and the dermisC.) Epidermis, dermis and the muscleD.) Epidermis, dermis, muscle and the bones

Ans: B

23.) Visual inspection of full-thickness burns would revealA.) Dry skin surface with a pearly white or charred appearanceB.) Blisters of varying sizes, with a cherry red baseC.) Moist skin surface with a mottled, reddened areaD.) A swollen, reddened area that blanches when pressure is applied

Ans: A

24.) What is the priority of care in the emergency room during the initial management of the burn client?A.) Obtaining a medical historyB.) Caring for the burn woundC.) Providing for fluid resuscitationD.) Administration of tetanus antitoxin as ordered

Ans: C

25.) During the first 24 hours post-burn, there is a fluid shift from the intravascular compartment to the site of burns. The nurse anticipates the following observations EXCEPT:A.) Decreased urine outputB.) Increased serum potassiumC.) Decreased hematocritD.) Decreased serum sodium

Ans: C

26.) The M.D. orders hourly CVP readings. The serial CVP readings are as follows: 3, 4, 6, 7, 8, cm of water. The nurse recognizes this as:A.) As indication to increase the flow rate of the IV fluidB.) A sign of fluid overloadC.) The desired response to the fluid therapyD.) An indication of the need to decrease the flow rate of the IV therapy

Ans: C

27.) The physicians prescribes Cimetidine (Tagamet) 400 mg every 6 hours per IV. The primary action of this drug is to prevent:A.) VomitingB.) Esophageal VaricesC.) Paralytic IleusD.) Duodenal ulcers

Ans: D

28.) The physician has ordered reverse isolation for Mr. M the nurse should understand that:A.) It is necessary to use sterile linens if the linens are properly washedB.) Sterile gowns, masks and gloves must be worn while caring for the clientC.) Only some persons coming in contact with the patients need to wear marks and glovesD.) It is not necessarily to wear mask while administering medication

Ans: B

29.) Mr. M becomes confused and restless. His CVP reading is 17 cm water, weight gain of 5 lbs and urine output of 100ml/hr. The nurse should recognize this as a signs of:A.) HypovolemiaB.) Circulatory overloadC.) The diuretic stageD.) Septic Shock

Ans: B

30.) During the diuretic phase of burns, fluid shifts from the interstitial compartment to the intravascular. There is increase urinary output. The ff changes occur during this stage:A.) Hypernatremia, hypokalemia, bicarbonate excessB.) Hyponatremia, hyperkalemia, carbonic acid deficits

C.) Hyponatremia, hyperkalemia, carbonic acid excessD.) Hyponatremia, hypokalemia, bicarbonate deficit

Ans: D

31.) The physician has ordered Mefenide Acetate (Sulfamylon) for the burn site every 12 hours. The nurse should recognize that:A.) There is a great deal of pain associated with the applicationB.) A thick layer of the preparation should e applied for maximum effectC.) Cover the application with pressure dressing for better effectD.) It is not necessary to use sterile technique during application of the preparation because it is antimicrobial

Ans: A

Situation: A female client, 60 y/o, is admitted through the emergency department with crushing substernal chest pain that radiates to her shoulder, jaw and left arm. The admission diagnosis is acute MI. The client is extremely restless and frightened

32.) The pain associated with MI is due to:A.) An overload left ventricleB.) Impending circulatory collapseC.) Imbalances in extracellular electrolytesD.) Insufficient oxygen reaching the heart muscle

Ans: D

33.) Which of the following hematological studies is typical finding of MI?A.) Elevated CPK valueB.) Elevated cholesterol levelC.) A below normal WBC countD.) A below normal ESR

Ans: A

34.) If the client has 8 PVC’s per minute, the nurse’s first course of action should be to:A.) Increase the rate of IV infusionB.) Notify the physician promptlyC.) Increase the concentration of oxygen therapyD.) Administer an analgesic prescribed for the client

Ans: B

35.) One change in the ECG that indicates MI is:A.) Inverted T waveB.) Prolonged PR intervalC.) Narrowing of the QRS complexD.) Absence of P wave

Ans: A

36.) If the client develops cardiogenic shock, which characteristic sign of the condition should the nurse expect to observe?A.) Pulmonary ralesB.) A slow pulse rateC.) Sudden onset of feverD.) A low blood pressure

Ans: D

37.) After one attack of pain, the client says to the nurse “husband died of heart attack and I suppose I will too” Which of the ff would be the most response for the nurse to make.A.) “Are you thinking that you won’t recover from this illness?”B.) “You have a fine doctor. Everything will be alright”C.) “Tell me more about what you are feeling”D.) “Would you agree that this would be very unlikely?”

Ans: C

38.) Which of the following orders should appear on the client’s NCP to help prevent Valsalva maneuver?A.) Have the client take fewer but deep breathesB.) Have the client clench her teeth while moving inC.) Have the client avoid holding her breath during activitiesD.) Have the client take oral fluids through a straw

Ans: C

39.) Oral furosemide (Lasix) is prescribed for the client. Which of the ff signs and symptoms indicates the need for this medication?A.) The client is anxiousB.) The client is restlessC.) The client has anterior chest painD.) The client has rales in the lower lobes of the lungs

Ans: D

Situation: Miss L, an acutely ill 17 y/o is admitted to the hospital with the chief complaint of upper respiratory infection. She is pale and weak. She has been diagnosed to have leukemia when she was 15.

40.) Which of the following statements best describes leukemia?A.) A disease is infectious in nature and characterized by increased WBC productionB.) The disease is neoplastic in nature and characterized by a proliferation of immature white blood cellsC.) The disease is inflammatory in nature and characterized by solid tumor formation in the lymph nodesD.) The disease is allergic in nature and characterized by an increased number of circulating antibodies in the bloodstream

Ans: B

41.) Laboratory findings of the client shows that she is anemic, which has most probably resulted from blood loss andA.) An inadequate intake of iron in the dietB.) An increase in destruction of RBC by lymphocytesC.) A progressive replacement of the bone marrow with scar tissueD.) A decrease in the production of RBC

Ans: D

42.) The nurse notes that the client has petechiae, her gums, lips and nose bleed easily, and that there are bruises on various parts of his body. Which of the following laboratory findings would be typical when theses symptoms appear?A.) Low platelet countB.) Low serum calcium levelC.) Faulty thrombin productionD.) Insufficient fibrinogen concentration

Ans: A

43.) Which of the following measures should be kept at a minimum, when possible because the client is prone to bruises and bleed easily?A.) Giving her stool softenerB.) Changing her position in bedC.) Offering her food at frequent intervalsD.) Administering drugs to her intramuscularly

Ans: D

44.) Which of the following measure would be contraindicated when the nurse gives the client oral hygiene?A.) Applying petroleum jelly to the lipsB.) Cleaning the teeth with hard-bristled toothbrushC.) Swabbing the mouth with moistened cotton swabsD.) Rinsing the mouth with a non-irritating mouth wash

Ans: B

45.) The nurse should question the order if the drug prescribed for Miss L. T o help control discomfort is:A. Acetaminophen (Tylenol)B.) Acetylsalicylic (Aspirin)C.) Paracetamol (Biogesic)D.) Acetophenetidin (Phenacetin)

Ans: B

46.) Miss L is scheduled for bone marrow aspiration. Over which of the following bone sites should the nurse prepare the client’s skin for entry of the needle?A.) The radiusB.) A sternumC.) A cervical vertebraD.) The posterior iliac crest

Ans: D

47.) The following are nursing consideration when administering oral iron preparation EXCEPT:A.) Use straw when taking liquid iron preparationB.) Take the medication with orange juiceC.) Inform that stool may become black and tarryD.) Take the medication before meals for better absorption

Ans: D

Situation: Mr. G, is a 45 y/o man, who has been diagnosed to have acute renal failure

48.) Mr. G has been prescribed low protein, potassium, and sodium diet. A touching program should include:

A.) Encourage to include raw fruits and vegetables in the dietB.) Inform that eggs, poultry and lean meat may be included in the dietC.) Point out that raw fruits such as bananas, watermelon and oranges have low potassium contentD.) Dried fish may be allowed in the diet

Ans: B

49.) During the first peritoneal dialysis exchange, the fluid that drains from the outflow tubing is tinged with blood. The nurse should:A.) Check the urine output for hematuriaB.) Apply a pressure dressing to the insertion siteC.) Recognize that the abdominal blood vessels have been inadvertently puncturedD.) Realize that this is an expected occurrence for the first few exchange

Ans: D

50.) To prevent abdominal cramps during peritoneal dialysis, the nurse should:A.) Instruct the client to lie flat during the entire exchange cycleB.) Infuse the dialyzing solution at a slow rateC.) Warm the dialysate solution to body temperatureD.) Drain the solution as soon as the inflow period is completed

Ans: C

51.) To promote drainage of fluid during the outflow period, the nurse shouldA.) Keep the head of the bed flatB.) Attach the outflow tubing to low suctionC.) Move the outflow tubing an inch in or outD.) Turn the client from side to side

Ans: D

Situation: After a serious automobile accident, a male client age 36 is transported by ambulance to the emergency room. He complains of severe pain in his right chest where he struck the steering wheel. He also experienced multiple lacerations and contusions

52.) The primary nursing goal at this point should be to:A.) Reduce anxietyB.) Maintain effective respirations

C.) Decrease chest painD.) Maintain adequate circulating volume

Ans: B

53.) Which of the following findings would confirm the presence of pneumothorax?A.) Pronounced ralesB.) Inspiratory wheezesC.) Dullness to percussionD.) Absence of breath sounds

Ans: D

54.) The nurse administers oxygen to the client by nasal cannula at 3L/min. What percentage of oxygen is the patient receiving?A.) %% to 10%B.) 15% to 20%C.) 30% to 35%D.) 50% to 60%

Ans: C

55.) A chest tube has been inserted, and has been removed on the 6th post op day. The chest tube is best removedA.) at the end of inhalation or during exhalation and do valsalva maneuverB.) During inhalationC.) As the patient do keep breathing exercisesD.) Anytime

Ans: A

56.) Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?A.) A butterfly dressingB.) A petrolatum gauze dressingC.) A scultetus binderD.) A 4x4 sterile gauze moistened with NSS

Ans: B

57.) The best position for the client undergoing thoracentesis is to maintain very still inA.) Lateral PositionB.) Supine positionC.) Sitting position and bending over an overbed tableD.) Prone position

Ans: C

58.) Nursing care during thoracentesis include

the ff. EXCEPT:A.) Observe for the rate, character of pulse and respiration, color and general appearance during the procedureB.) Encourage the patient to cough and deep breathe after the needle is insertedC.) Place the patient on the unaffected side for one hour after the procedureD.) Monitor VS after the procedure to detect hemorrhage and impending shock

Ans: B

59.) Health teachings to a client with bronchial asthma include the following EXCEPT:A.) Avoid emotional stress, extremes of temperatureB.) Avoid personal pollution such as smokingC.) Avoid dust, pollens, and animal dandersD.) Practice respiratory isolation

Ans: D

60.) A patient as diagnosed to have laryngeal CA. which of the following is viewed as the primary predisposing factors?A.) Cigarette smokingB.) Excessive alcoholC.) Voice strainD.) Environmental pollutants

Ans: A

61.) An early manifestation of laryngeal CA isA.) Weight lossB.) DysphagiaC.) Hoarseness of voiceD.) Lump in the neck

Ans: C

62.) The patient had laryngectomy. The following are expected after the surgery EXCEPT:A.) A tracheostomy in placeB.) ConstipationC.) Loss of sense of smellD.) An Endotracheal tube in place

Ans: D

63.) A client has pleural effusion. Percussion sound would most likely be:A.) DullB.) FlatC.) Tympanic

D.) Resonant

Ans: A

64.) Risk factors that may produce pulmonary emboli and deep vein thrombosis include the ff EXCEPT:A.) ImmobilityB.) ObesityC.) Pelvic surgeries, orthopedic surgeries of lowerD.) Early ambulation post op

Ans: D

65.) In chest injury, cautious and judicious administration of analgesic is indicated to prevent respiratory depression. Which of the ff drug may be given in small doses?A.) Pancuronium Hydrobromide (Pavulcon)B.) Morphine SulfateC.) Succinylcholine (Anectine)D.) Meperidine HCL ( Demerol)

Ans: D

66.) Nursing interventions to a client with bronchogenic CA include the ff EXCEPT:A.) Administration of oxygen inhalation therapy as orderedB.) performing chest percussion and vibrationC.) Administration of medimist inhalation therapy as orderedD.) Promotion of physical comfort and physiological support

Ans: B

67.) The following are nursing responsibilities when caring for a patient with tracheostomy tube:A.) Apply suction for no longer than 10-15 secondsB.) Instill 5 mls of sterile NSS to the tracheostomy tube to liquefy mucous secretions as neededC.) use clean technique when suctioning tracheostomy tubeD.) Insert 3-5 inches length of suction catheter

Ans: C

68.) The following are nursing responsibilities to a patient who had undergone tonsillectomy EXCEPT:A.) Place in lateral position with the head down

until fully awakeB.) Observe for frequent swallowingC.) Instruct to avoid clearing the throat, coughingD.) Allow to drink fluids through a straw

Ans: D

69.) The first aid treatment of epistaxis includes which of the following?A.) Exerting pressure at the soft tissues of the noseB.) Tilting the head backC.) Inserting cotton swabs into naresD.) Applying hot compress over the nose

Ans: A

70.) A client is scheduled for a transurethral resection of the prostate (TURP) tomorrow. During outpatient preop teaching, he asks where his incision will be. What is the most appropriate response?A.) “The incision is made in the abdomen”B.) “The incision is made in the lower abdomen”C.) “The incision is made in the perineum between the scrotum and the rectum”D.) “There is no incision. The Doctor inserts an instrument through the urethra, the opening in the penis

Ans: D

71.) When a client after prostectomy returns from the recovery room he has an IV infusing at 100ml/hr., a three Foley catheter in place, and continuous bladder irrigation. What would the nurse do first when increase blood in the urine is detected?A.) Increase the speed of the irrigationB.) Release the traction on the FoleyC.) Irrigate the catheter manuallyD.) Notify the physician

Ans: A

72.) A client who had a TURP complains of pain and bladder spasms. Which of the following nursing actions is most appropriate after determining that the drainage system is patent?A.) Administer narcotics plus anticholinergic drugs, as orderedB.) Help him to sitz bathC.) Decrease the speed of the irrigationD.) Decrease the traction on the Foley

Ans; A

73.) Which of the following would be included in the discharge teaching for a prostectomy client?A.) “Avoid straining at stools”B.) “Avoid heavy lifting for approximately one week after surgery”C.) “Drive your care whenever you are ready to do so”D.) “Refrain from sexual intercourse for 12 weeks”

Ans: A

74.) Which of the following statements indicates that a prostectomy client understand his discharge instruction?A.) “I know my urine maybe slightly pink-tinged”B.) “I know my urine should be clear all the time”C.) “I know my urine should be clear most of the timeD.) “I’ll let my doctor knows if I have any urinary dribbling, retention or bleeding”

Ans: D

75.) Which of the following is a common early symptom of prostate hypertrophy?A.) Difficulty urinatingB.) ImpotenceC.) Urinary InfectionD.) Hematuria

Ans: A

76.) The physician wants to examine a client’s prostate gland. What equipment will be necessary for the exam?A.) A Foley catheterB.) Lubricant and glovesC.) Urethral dilatorsD.) A rectal tube

Ans: B

77.) A client undergoes TURP under spinal anesthesia. He returns to his room with continuous bladder irrigation (CBI). Which of these statements best explains the reason for the CBI?A.) To decrease bladder atonyB.) To remove blood clots from the bladderC.) To maintain patency of the urethral catheterD.) To dilute the concentrated urine

Ans: B

78.) Which of the following symptoms can be expected temporarily when a client’s Foley catheter is removed?A.) UrgencyB.) DribblingC.) Urinary retentionD.) Decreased urinary output

Ans: B

79.) Which of the following is the most common complication following a prostectomy that has implications for nursing assessment and intervention?A.) Urinary tract infectionB.) Cardiac ArrestC.) PneumoniaD.) Thrombophlebitis

Ans: D

80.) Which of the following is the most appropriate when preparing a client for a proctosigmoidoscopy?A.) On the morning of the examination administer enemas until the returns are clearB.) Maintain the client NPO for 24 hours preceding the examinationC.) Give a strong cathartic on both the evening before and the morning of the examinationD.) Give sitz bath three times daily for 3 days preceding the examination

Ans: A

81.) What position is best for a client during a proctoscopic examination?A.) ProneB.) Right SimsC.) LithotomyD.) Knee chest

Ans: D

82.) Which nursing response is the most appropriate when preparing a client for a proctosigmoidoscopy?A.) “You need have no anxiety concerning this procedure. You will exercise no pain or discomfort”B.) “You will experience a feeling of pressure and the desire to move your bowels during the brief time that the scope is in place”C.) “You can reduce your discomfort during the procedure to a minimum by bearing down as the prostoscope is introduced”

D.) “You will experience no discomfort during the procedure, because a topical anesthetic will be applied to the anus”

Ans: B

83.) Which of the following is most characteristic of the stools in ulcerative colitis?A.) DiarrheaB.) Clay-colored with blood and mucusC.) Gray and foamyD.) Semisolid, green with blood and mucus

Ans: A

84.) A colectomy and ileostomy are proposed for a client. This surgery involves which of the following?A.) Removal of the rectum with a portion of the colon brought through the abdominal wallB.) Removal of the colon with a portion of the ileum brought through the abdominal wallC.) Removal of the ileum with portion of the colon brought through the abdominal wallD.) A “pull-through” procedure

Ans: B

85.) Which of the following is not anticipated after an ileostomy?A.) Weight gainB.) Liquid stoolC.) Reestablishment of a regular bowel patternD.) Irritation of the skin around the stoma

Ans: A

86.) Skin care around a stoma is critical. In colostomy skin care, which of the following is contraindicated?A.) Observe for any excoriated areasB.) Use karaya paste and rings around the stomaC.) Apply mineral oil to the area for moistureD.) Clean the area daily with soap and water before applying the bag

Ans: C

87.) Regulation of a colostomy will be most enhanced if the clientA.) Eats balanced meals at regular intervalsB.) Irrigates after lunch each dayC.) Restricts exercise to walking onlyD.) Eats fruit all three meals

Ans: A

88.) When helping a client to accept his colostomy, which of the following actions is inappropriate?A.) Encourage him to look at the stomaB.) Emphasize his positive attributesC.) Involve the family in his careD.) Have him do his own irrigation

Ans: D

89.) A gastric suction tube was inserted before a client was sent to surgery, in order to:A.) Facilitate administration of high caloric, nutritious liquids immediately after completion of the procedureB.) Prevent accumulation of gas and fluid in the stomach both during and following surgical actionC.) Provide a reliable means of detecting gastrointestinal hemorrhage during the operative procedureD.) Serve as s stimulus to restore normal peristaltic movement following recovery from anesthesia

Ans: B

90.) The symptoms of colon cancer vary depending on where in the colon lesion is located. Which would not be a classic symptom of colon cancer?A.) Change in bowel habitsB.) Excessive flatusC.) pain on the right upper quadrant of the abdomenD.) Anorexia and nausea

Ans: C

91.) Which of the following diagnostic tests will confirm the diagnosis of colon cancer most conclusively?A.) Carcinoembryonic antigen (CEA)B.) Barium EnemaC.) Biopsy of the lesionD.) Stool examination

Ans: C

92.) A 30 y/o homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face, head and neck, anterior chest and both arms and hands. Using the “rule of nine” which of the following is the best estimate

of total body surface area burned?A.)18%B.) 22%C.) 36%D.) 40%

Ans: C

93.) Which of the following would be characteristic of a fresh, second degree burn?A.) Absence of pain and pressure senseB.) White or dark, dry, leathery appearanceC.) Large, thick blistersD.) Visible, thrombosed small vessels

Ans: C

94.)with the location of burns over the upper torso, what is the nurse’s primary concern?A.) Debride and dress the woundsB.) Initiate and administer antibioticsC.) Frequently observe for hoarseness, stridor and dyspneaD.) Obtain a thorough history of events leading to the accident

Ans: C

95.) A narcotic IV was ordered to control the pain of a client with burns. Why was the IV route selected?A.) Burns cause excruciating pain, requiring immediate reliefB.) Circulatory blood volume is reduced, delaying absorption from subcutaneous and muscle tissueC.) Cardiac function is enhanced by immediate action of the drugD.) Metabolism of the drug would be delayed because of decreased insulin production

Ans: B

96.) A major goal for the client during the first 28 hours after severe burns is to prevent hypovolemic shock. Which of the following would not be a useful monitor of fluid restitution during this period?A.) Elevated hematocritB.) Urine output of 30 ml/hrC.) Change in sensoriumD.) Estimate of fluid loss through the burn eschar

Ans: D

97.) Mafenide acetate (Sulfamylon) is applied to a burned client’s wound every 12 hours, the nurse’s assessment would include observation for which of the following side effects of this drug?A.) Metabolic acidosisB.) Discoloration of the skinC.) Laceration of the skinD.) Dehydration and electrolytes loss

Ans: A

98.) Contractures are among the most serious of the long-term complications of a burn. Because of the burn location on the upper torso, which of the following measures would most likely cause a client to have contractures?A.) Change the location of the bed or the TV set, or both, dailyB.) Encourage the client to chew gum and blow up balloonsC.) Avoid using a pillow or place the head in a portion of hyperextensionD.) Allow the client to assume a position of comfort

Ans: D

99.) What is the primary aim of all burn-wound care?A.) To debride the wound of dead tissue and escharB.) To limit fluid loss through the skinC.) To prevent growth of microorganismsD.) To decrease formation of disfiguring scars

Ans: C

100.) Deep partial thickness burns (2nd degree) involves the:A.) EpidermisB.) Entire epidermis and the dermisC.) Epidermis, dermis and the musclesD.) Epidermis, dermis, muscle and the bones