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.)

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Position the head of the bed flat.

Answer and Explanation

Correct Answer : B,C,D

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

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Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

A. Avoid intramuscular injections B. Include orange juice when taking iron C. Avoid green leafy vegetables D. Avoid live immunizations

Correct Answer is B

Explanation

Choice A rationale
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
Choice B rationale
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
Choice C rationale
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
Choice D rationale
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is educating a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

Correct Answer is B

Explanation

When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area. Which patient should be attended to first?

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?

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. When should the nurse plan to administer the medication?

A nurse is educating a patient with osteoporosis who has been prescribed alendronate 70 mg PO weekly (Fosamax). Which statement by the patient indicates a need for further instruction?