Nursing Elites

1. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

• A. Infection
• B. Airway obstruction
• C. Fluid imbalance
• D. Pain management

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

2. A nurse is teaching a client about the use of omeprazole. Which of the following should be included?

• A. Take the medication with food
• B. Avoid taking it with NSAIDs
• C. Monitor for gastrointestinal bleeding
• D. It can cause drowsiness

Correct answer: C

Rationale: The correct answer is C. Omeprazole is a proton pump inhibitor that can mask symptoms of gastrointestinal bleeding; clients should be monitored for this. Choices A and B are incorrect because omeprazole is usually taken before meals, and while it is important to avoid NSAIDs if possible due to their effects on the stomach, it is not directly related to omeprazole use. Choice D is also incorrect as omeprazole is not typically associated with causing drowsiness.

3. While providing education about the use of lorazepam, which of the following should be included?

• A. It can cause dependency
• B. It can be taken with alcohol
• C. It has no side effects
• D. It is a stimulant

Correct answer: A

Rationale: The correct answer is A: 'It can cause dependency.' Lorazepam is a benzodiazepine known to cause dependency, so it is crucial for clients to be informed about this potential risk. Choice B is incorrect as combining lorazepam with alcohol can lead to increased sedation and other adverse effects. Choice C is incorrect because lorazepam, like any medication, can have side effects such as drowsiness, dizziness, or confusion. Choice D is also incorrect as lorazepam is a sedative-hypnotic medication, not a stimulant.

4. A client is being taught about the use of nitroglycerin. Which of the following should be included?

• A. Take it with food
• B. Place the tablet under the tongue
• C. It can be stored in the refrigerator
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is to place the nitroglycerin tablet under the tongue. Nitroglycerin tablets are meant for sublingual absorption during angina episodes to provide quick relief. Option A is incorrect because nitroglycerin should not be taken with food. Option C is incorrect as nitroglycerin should be stored in a cool, dark place, not in the refrigerator. Option D is incorrect because nitroglycerin can have side effects, including headaches, dizziness, and low blood pressure.

5. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?

• A. Decrease the oxytocin infusion
• B. Discontinue the oxytocin infusion
• C. Increase the IV fluid rate
• D. Apply an internal fetal monitor

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.

Similar Questions