Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing care for a client with severe burns.
The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)
A. Cool the burn with ice water.
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
B. Administer opioid analgesics.
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
C. Administer systemic antibiotics.
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
D. Administer benzodiazepines for anxiety management.
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
E. Position the head of the bed flat.
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore
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Full Explanation
Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore
Similar Questions
The nurse is instructing a patient on how to administer 0.5 mg of epinephrine intramuscularly.
If the available dose is 0.5 mg/0.5 mL, how many mL should the patient be taught to administer?
Full Explanation
Step 1: The available dose of epinephrine is 0.5 mg in 0.5 mL.
Step 2: The patient needs to administer 0.5 mg of epinephrine.
Step 3: Since the available dose is 0.5 mg/0.5 mL, for 0.5 mg of epinephrine, the patient should be taught to administer 0.5 mL1.
A nurse is assessing a client with a major burn injury.
Which of the following findings should the nurse prioritize?
A. The client is producing black colored sputum.
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
B. The client has large blistered areas over his chest.
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
C. The client has edema at the burn site.
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
D. The client has decreased sensation over the burn areas.
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
Full Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
The nurse is caring for an 85-year-old patient with septic shock.
What should the nurse consider when repositioning this patient?
A. Place the patient in the Trendelenburg position.
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
B. Change the patient’s position slowly.
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
C. Reduce the oxygen flow.
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
D. Increase the IV fluid flow.
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.
Full Explanation
Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.