Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
A. Within 12 hours after burn trauma
Within 12 hours after burn trauma: Fluid loss is significant initially but peaks later.
B. 48 to 72 hours after burn trauma
48 to 72 hours after burn trauma: The greatest fluid loss typically occurs within the first 48 to 72 hours as capillary permeability is at its highest and fluid resuscitation needs are greatest.
C. 24 to 36 hours after burn trauma
24 to 36 hours after burn trauma: Fluid loss is still considerable but not at its peak; the peak is generally observed a bit later.
D. 36 to 48 hours after burn trauma
36 to 48 hours after burn trauma: Fluid loss continues to be high, but the peak is generally reached a little later than this timeframe.
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Full Explanation
A. Within 12 hours after burn trauma: Fluid loss is significant initially but peaks later.
B. 48 to 72 hours after burn trauma: The greatest fluid loss typically occurs within the first 48 to 72 hours as capillary permeability is at its highest and fluid resuscitation needs are greatest.
C. 24 to 36 hours after burn trauma: Fluid loss is still considerable but not at its peak; the peak is generally observed a bit later.
D. 36 to 48 hours after burn trauma: Fluid loss continues to be high, but the peak is generally reached a little later than this timeframe.
Similar Questions
A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?
A. Delirium
Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break
Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke
Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder
Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
Full Explanation
A. Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?
A. A resident with dementia who requires assistance eating.
A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.
B. A resident who is sexually active
A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.
C. A resident who is undergoing chemotherapy for breast cancer
A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.
D. A resident recovering from a hip fracture
A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.
Full Explanation
A. A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.
B. A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.
C. A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.
D. A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.
The nurse recommends a breathing technique to help a patient with chronic obstructive pulmonary disease (COPD) to empty the lungs of used air and to promote inhalation of adequate oxygen. What is this method of breathing called?
A. Decreased expiration
Decreased expiration: This term does not refer to a specific breathing technique used for COPD.
B. Pursed-lip breathing
Pursed-lip breathing: Pursed-lip breathing helps patients with COPD to maintain open airways, increase expiratory time, and improve oxygen exchange.
C. Increased Inspiration
Increased Inspiration: This term is not a recognized technique and may lead to incorrect breathing practices.
D. Vital capacity
Vital capacity: Vital capacity is a measure of lung volume and is not a breathing technique.
Full Explanation
A. Decreased expiration: This term does not refer to a specific breathing technique used for COPD.
B. Pursed-lip breathing: Pursed-lip breathing helps patients with COPD to maintain open airways, increase expiratory time, and improve oxygen exchange.
C. Increased Inspiration: This term is not a recognized technique and may lead to incorrect breathing practices.
D. Vital capacity: Vital capacity is a measure of lung volume and is not a breathing technique.