Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an emergency department is caring for a client who has deep partial- and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?
A. Medicate for pain.
B. Maintain the airway.
This is because inhalation injury can cause airway edema, obstruction, and respiratory failure, which can be life-threatening. The nurse should monitor the client's respiratory status, administer oxygen, and prepare for intubation if needed.
C. Insert an indwelling urinary catheter.
D. Initiate fluid resuscitation.
This question is an excerpt from Nurse Dive's nursing test bank - ATI SP 250 Exam 3 Med Surg Proctored Exam. Take the full exam now
Full Explanation
This is because inhalation injury can cause airway edema, obstruction, and respiratory failure, which can be life-threatening. The nurse should monitor the client's respiratory status, administer oxygen, and prepare for intubation if needed.
Similar Questions
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
A. Provide the client with fresh fruit to avoid constipation.
B. Insert an indwelling catheter to monitor sediment in the urine.
C. Take the client's temperature once per shift.
D. Limit the number of health care workers entering the room.
This is because immunosuppression increases the risk of infection, and health care workers can be potential sources of pathogens. The nurse should use standard precautions, avoid invasive procedures, and restrict visitors who are ill.
Full Explanation
This is because immunosuppression increases the risk of infection, and health care workers can be potential sources of pathogens. The nurse should use standard precautions, avoid invasive procedures, and restrict visitors who are ill.
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
A. Mantoux test
B. Sputum culture for acid-fast bacillus
This is because sputum culture can identify the presence and type of mycobacteria that cause TB, while other tests can only indicate exposure or infection. Sputum culture results may take several weeks, so treatment should be initiated based on clinical suspicion and other tests.
C. Sputum smear
D. Chest x-ray
Full Explanation
This is because sputum culture can identify the presence and type of mycobacteria that cause TB, while other tests can only indicate exposure or infection. Sputum culture results may take several weeks, so treatment should be initiated based on clinical suspicion and other tests.
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
A. Lethargy
This is because pulmonary tuberculosis causes inflammation and damage to the lungs, which reduces oxygen exchange and leads to fatigue and weakness.
B. Dry cough
C. Weight gain
D. High-grade fever
Full Explanation
This is because pulmonary tuberculosis causes inflammation and damage to the lungs, which reduces oxygen exchange and leads to fatigue and weakness.