One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Explain the need for skin exposure to sunlight without sunscreen.

Teach the need for dietary and supplemental vitamin D.

Instruct the client in the use of muscle strengthening exercises.

Encourage progressive active range of motion.

Answer and Explanation

The Correct Answer is B

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

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Correct Answer is D

Explanation

Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.

Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.

Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.

Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.

A. An adult who is one day postoperative for a laparoscopic cholecystectomy. B. An older client who is one day postoperative with a colostomy for colon cancer. C. An older adult who is scheduled for foot amputation due to diabetes complications. D. An adult with alcoholism, cirrhosis, and hepatic encephalopathy.

Correct Answer is A

Explanation

Choice A reason: This client is relatively stable and the care required is within the scope of practice for a practical nurse (PN). Postoperative care for a laparoscopic cholecystectomy typically involves monitoring vital signs, pain management, and encouraging early ambulation, which the PN can perform with supervision.

Choice B reason: The older client with a colostomy for colon cancer may require more complex care and education about stoma management, which might be better suited for the RN.

Choice C reason: An older adult scheduled for foot amputation due to diabetes complications may have complex needs related to diabetes management and preoperative care, which require the RN's expertise.

Choice D reason: An adult with alcoholism, cirrhosis, and hepatic encephalopathy requires close monitoring for changes in mental status and liver function, which is more appropriate for the RN to manage.

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One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

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