The practical nurse (PN) is caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg. Which priority action should the PN take while caring for this patient?

Anticipate rehydration of 1000 mL/6 hr. with normal saline.

Remove clothing, cover burned area with cool damp cloth.

Completely ﬂush burned area with water or sterile saline.

Collect data, vital signs, blood gases, height and weight.

Answer and Explanation

The Correct Answer is B

The priority action for the practical nurse (PN) to take while caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg is to remove clothing and cover the burned area with a cool damp cloth. This will help to cool the burn and reduce pain.

Anticipating rehydration of 1000 mL/6 hr. with normal saline (Option A) is an important intervention for burn patients, but it is not the first priority. Completely ﬂushing the burned area with water or sterile saline (Option C) may be appropriate in some cases, but it is not the first intervention that should be implemented. Collecting data such as vital signs, blood gases, height and weight (Option D) is also important, but it is not the first priority.

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Correct Answer is D

Explanation

Gestational diabetes mellitus (GDM) is a type of diabetes that occurs during pregnancy. If euglycemia, or normal blood glucose levels, is not maintained during pregnancy, the fetus can be at risk for a number of complications. The greatest risk to the fetus in this situation is the development of a macrosomic newborn, or a newborn that is significantly larger than average. This occurs because the excess glucose in the mother's bloodstream is passed on to the fetus, leading to excessive fetal growth.

Macrosomia can lead to complications during delivery, such as shoulder dystocia, and can increase the risk of injury to both the mother and the baby. While low birth weight and preterm birth are also potential complications of GDM, macrosomia is considered the greatest risk to the fetus if euglycemia is not maintained. Cleft palate is not typically associated with GDM.

A. Cheeseburger and French fries. B. Baked chicken with rice. C. Pasta with steamed vegetables. D. Baked potato chips and lemonade.

Correct Answer is A

Explanation

During pregnancy, it is important for the client to consume a balanced and nutritious diet that includes adequate protein, vitamins, and minerals. However, clients with nausea and vomiting may have difficulty tolerating certain foods, particularly those that are high in fat or spicy. Cheeseburgers and French fries are typically high in fat and can exacerbate nausea, making them a poor choice for a client with this symptom.

Baked chicken with rice and pasta with steamed vegetables are both healthier options that can provide the client with adequate nutrition.

Baked potato chips and lemonade may be a suitable snack for some clients, but the high salt content of the chips may exacerbate ﬂuid retention, which can be a concern for clients with pyelonephritis. The PN should encourage the client to choose healthier options and avoid foods that are likely to exacerbate her symptoms.

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The practical nurse (PN) is caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg. Which priority action should the PN take while caring for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who has been diagnosed with gestational diabetes mellitus. Which complication should the PN recognize as the greatest risk to the fetus if euglycemia is not maintained?

Correct Answer is D

Explanation

A primigravida who is at 10-weeks gestation is hospitalized on the antepartum unit for pyelonephritis. The client tells the practical nurse (PN) that she has had several episodes of nausea. When reviewing her lunch menu, which food should the PN discourage her from choosing?

Correct Answer is A

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the practical nurse (PN) to ask?

The mother of a 3-year-old asks the practical nurse (PN) to clarify the healthcare provider's diagnosis of acute otitis media. Which is the most accurate explanation?

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The practical nurse (PN) is caring for a newborn whose mother has poorly controlled type 1 diabetes mellitus and observes the newborn is grunting with mild sternal retractions. The PN should recognize the newborn is exhibiting signs of which condition?

A normal newborn is admited to the nursery and receives an injection of Phytonadione. The father is watching the nurse administer the injection and asks the practical nurse (PN), "Will my baby get another injection before we can go home?" Which response is best for the PN to provide?

The practical nurse (PN) is discussing attention deficit hyperactivity disorder (ADHD) with the mother of a 7- year-old student newly diagnosed with the disorder. Which intervention should the PN suggest as most eﬀective in managing the symptoms of ADHD?