Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?
A. Transport victim to hospital.
Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.
B. Stop, drop, and roll.
Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.
C. Cover victim with clean cloth or sheet.
Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.
D. Remove all nonadherent clothing and jewelry.
Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.
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Full Explanation
A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.
B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.
C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.
D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.
Similar Questions
A nine-year-old patient is being evaluated for a skin rash. The preliminary diagnosis is impetigo contagiosa. The nurse assists with planning care with which fact about impetigo contagiosa in mind?
A. is present in all age-groups, but especially older adults
is present in all age-groups, but especially older adults : Impetigo is more common in children and not especially prevalent in older adults.
B. Usually presents with a rash on the patient's back
Usually presents with a rash on the patient's back: Impetigo typically presents on exposed areas such as the face, arms, and legs, not usually the back.
C. Is a highly contagious inflammatory disorder
Is a highly contagious inflammatory disorder: Impetigo is highly contagious and characterized by inflammatory skin lesions.
D. is a viral skin infection
is a viral skin infection: Impetigo is caused by bacterial infection (usually Staphylococcus aureus or Streptococcus pyogenes), not a virus.
Full Explanation
A. is present in all age-groups, but especially older adults : Impetigo is more common in children and not especially prevalent in older adults.
B. Usually presents with a rash on the patient's back: Impetigo typically presents on exposed areas such as the face, arms, and legs, not usually the back.
C. Is a highly contagious inflammatory disorder: Impetigo is highly contagious and characterized by inflammatory skin lesions.
D. is a viral skin infection: Impetigo is caused by bacterial infection (usually Staphylococcus aureus or Streptococcus pyogenes), not a virus.
A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?
A. Prevention of infection and promote healing.
Prevention of infection and promote healing. Debridement helps remove dead tissue, which prevents infection and promotes healing.
B. Promoting movement in the affected area.
Promoting movement in the affected area: While movement is important, debridement is primarily for removing necrotic tissue to prevent infection.
C. To increase the effectiveness of the skin graft.
To increase the effectiveness of the skin graft: Debridement does help prepare the wound bed for grafting, but its main purpose is infection control and healing.
D. Promoting suppuration of the wound.
Promoting suppuration of the wound: Suppuration is not a goal of debridement; it is about cleaning the wound and preventing infection.
Full Explanation
A. Prevention of infection and promote healing. Debridement helps remove dead tissue, which prevents infection and promotes healing.
B. Promoting movement in the affected area: While movement is important, debridement is primarily for removing necrotic tissue to prevent infection.
C. To increase the effectiveness of the skin graft: Debridement does help prepare the wound bed for grafting, but its main purpose is infection control and healing.
D. Promoting suppuration of the wound: Suppuration is not a goal of debridement; it is about cleaning the wound and preventing infection.
A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized?
A. Anger
Anger: Anger is a common response but not necessarily the most immediate concern in the context of severe emotional distress and potential suicidal thoughts.
B. Fear
Fear: Fear is a possible reaction, but suicidal ideation is a more serious concern in the context of helplessness and hopelessness.
C. Isolation
Isolation: Isolation may occur, but suicidal ideation is a critical issue that requires immediate attention.
D. Suicidal ideation
Suicidal ideation: Feelings of helplessness and hopelessness can be strong indicators of suicidal ideation, which should be assessed and addressed urgently.
Full Explanation
A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.
B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.
C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.
D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.