Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.
Which of the following interventions should the nurse perform first?
A. Administer pain medication.
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
B. Administer a tetanus booster.
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
C. Clean and dress the wound.
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
D. Administer IV fluids.
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.
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Full Explanation
Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.
Similar Questions
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?
A. Fluoxymesterone.
Fluoxymesterone is a synthetic anabolic steroid but it’s not used for BPH.
B. Danazol.
Danazol is a synthetic steroid that is used to treat endometriosis, but it’s not used for BPH.
C. Methyltestosterone.
Methyltestosterone is a synthetic anabolic steroid but it’s not used for BPH.
D. Finasteride.
Finasteride is a medication that is used to treat BPH. It works by decreasing the size of the prostate gland.
Full Explanation
Choice A rationale:
Fluoxymesterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice B rationale:
Danazol is a synthetic steroid that is used to treat endometriosis, but it’s not used for BPH.
Choice C rationale:
Methyltestosterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice D rationale:
Finasteride is a medication that is used to treat BPH. It works by decreasing the size of the prostate gland.
A nurse is assessing a client who is brought to the emergency room with burn injuries.
Which of the following findings should the nurse identify as a deep partial-thickness burn?
A. The burned area is pink in color with blisters present.
A pink color with blisters present is indicative of a superficial partial-thickness burn, not a deep partial-thickness burn.
B. The burned area is yellow in color with severe edema.
A yellow color with severe edema is indicative of a deep partial-thickness burn. This type of burn involves the entire dermis and damage to nerve endings, blood vessels, and sweat glands.
C. The burned area is black in color and pain is absent.
A black color and absence of pain is indicative of a full-thickness burn, not a deep partial-thickness burn.
D. The burned area is red in color with eschar present.
A red color with eschar present is indicative of a full-thickness burn, not a deep partial-thickness burn.
Full Explanation
Choice A rationale:
A pink color with blisters present is indicative of a superficial partial-thickness burn, not a deep partial-thickness burn.
Choice B rationale:
A yellow color with severe edema is indicative of a deep partial-thickness burn. This type of burn involves the entire dermis and damage to nerve endings, blood vessels, and sweat glands.
Choice C rationale:
A black color and absence of pain is indicative of a full-thickness burn, not a deep partial-thickness burn.
Choice D rationale:
A red color with eschar present is indicative of a full-thickness burn, not a deep partial-thickness burn.
A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort.
Which of the following instructions should the nurse include in the teaching?
A. "Limit your dietary intake of salt prior to menses.”.
Limiting dietary intake of salt prior to menses can help reduce fluid retention and breast swelling, thus minimizing discomfort.
B. "Take tub baths to avoid hot water running over your breast tissue.”.
Taking tub baths doesn’t necessarily minimize discomfort associated with FBC. Hot water running over the breast tissue doesn’t have a significant impact on FBC symptoms.
C. "Remove your bra at night while sleeping.”.
Removing the bra at night might provide some relief but it’s not a primary strategy for minimizing discomfort in FBC.
D. "Reduce your fluid intake to 1 liter per day during menstruation.”.
Reducing fluid intake to 1 liter per day during menstruation is not recommended. Adequate hydration is important for overall health.
Full Explanation
Choice A rationale:
Limiting dietary intake of salt prior to menses can help reduce fluid retention and breast swelling, thus minimizing discomfort.
Choice B rationale:
Taking tub baths doesn’t necessarily minimize discomfort associated with FBC. Hot water running over the breast tissue doesn’t have a significant impact on FBC symptoms.
Choice C rationale:
Removing the bra at night might provide some relief but it’s not a primary strategy for minimizing discomfort in FBC.
Choice D rationale:
Reducing fluid intake to 1 liter per day during menstruation is not recommended. Adequate hydration is important for overall health.