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 B

Explanation

Choice A rationale
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the esophagus, irritating the lining and causing symptoms like heartburn. Protonix (pantoprazole) is a proton pump inhibitor that decreases the amount of acid produced in the stomach. While it is used to treat GERD, it is not typically used prophylactically in trauma patients.
Choice B rationale
Stress ulcers are a type of peptic ulcer that is particularly common in critically ill or severely stressed patients, such as those with severe trauma like an automobile accident. These ulcers occur when the body’s physical stress leads to increased gastric acid secretion, which can damage the gastric mucosa and lead to ulcers. Protonix, by reducing stomach acid, can help prevent these ulcers in high-risk patients. This is why it is often administered prophylactically in severe trauma cases.
Choice C rationale
Dumping syndrome is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. It’s also known as rapid gastric emptying. Protonix is not typically used to prevent dumping syndrome.
Choice D rationale
Gastritis is an inflammation of the stomach lining. While Protonix can be used to treat gastritis, it is not typically used prophylactically for this condition in trauma patients.

A. Eat foods that contain plenty of potassium. B. Take the medication at bedtime. C. Take aspirin for headaches. D. Expect some swelling in the hands and feet.

Correct Answer is A

Explanation

Choice A rationale

Furosemide is a diuretic, or water pill, that helps your body get rid of extra salt and water. It can cause you to lose too much potassium, a mineral that helps your nerves, muscles, and organs work normally. So, it’s important to eat foods that are high in potassium, such as bananas, oranges, tomatoes, beans, and spinach.

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Naxlex Comprehensive Predictor Exams

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

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

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 client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement. Which of these actions should the nurse take to effectively assist the patient?

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain. Which is the correct instruction?

Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?

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?