Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
A. Insert an indwelling urinary catheter.
B. Draw blood for a complete blood cell (CBC) count.
C. Inspect the mouth for signs of inhalation injuries.
This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
D. Administer intravenous pain medication.
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 injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
Similar Questions
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?
A. Nucleic acid amplification test (NAAT)
This is because a NAAT can detect the presence of Mycobacterium tuberculosis DNA in a sputum sample within hours, which can confirm the diagnosis and guide treatment decisions. A sputum culture for AFB can take several weeks to yield results, while a chest x-ray or a CT scan can only show suggestive findings but not confirm the diagnosis.
B. Sputum culture for acid-fast bacillus (AFB)
C. Chest x-ray
D. CT scan
Full Explanation
This is because a NAAT can detect the presence of Mycobacterium tuberculosis DNA in a sputum sample within hours, which can confirm the diagnosis and guide treatment decisions. A sputum culture for AFB can take several weeks to yield results, while a chest x-ray or a CT scan can only show suggestive findings but not confirm the diagnosis.
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
A. Soles of the feet
B. Ear lobes
C. Oral mucosa
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
D. Conjunctivae
Full Explanation
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?
A. Propranolol
The nurse should clarify with the provider why this medication is ordered and if there are any alternatives that are safer for the client. The other medications are appropriate for a client who has asthma.
B. Theophylline
C. Montelukast
D. Prednisone
Full Explanation
The nurse should clarify with the provider why this medication is ordered and if there are any alternatives that are safer for the client. The other medications are appropriate for a client who has asthma.