1.
You notice that in a patient who has severe burns, the fluid is starting to accumulate in that patient's abdominal tissue. There is no change in his weight, and his intake and output are equal. What is that you suspect?
Correct Answer
C. Third spacing
Explanation
In severe burns, the body's response to injury can cause fluid to shift from the intravascular space (blood vessels) to the interstitial space (spaces between cells). This is known as third spacing. Third spacing can lead to fluid accumulation in tissues, such as the abdominal tissue, without a change in weight or a significant difference in intake and output. Therefore, the presence of fluid accumulation in the abdominal tissue without any other significant changes suggests third spacing as the likely cause.
2.
X patient is suffering from constipation; as a nurse, according to you, which is the appropriate nursing intervention for maintaining normal bowel function?
Correct Answer
D. Assessing dietary intake
Explanation
Assessing dietary intake is the appropriate nursing intervention for maintaining normal bowel function in a patient suffering from constipation. By assessing the patient's dietary intake, the nurse can identify any deficiencies or excesses in fiber, fluids, and other nutrients that may be contributing to the constipation. This information can then be used to develop a personalized plan to improve the patient's bowel function, such as increasing fiber intake or recommending specific dietary changes.
3.
Two days ago, a 12-13 years old boy was admitted due to hyperthermia. Which nursing interventions should be chosen in the client's care plan?
Correct Answer
D. Room temperature reduction
Explanation
The correct answer is room temperature reduction. Hyperthermia is a condition characterized by an elevated body temperature. In order to help the client lower their body temperature, it is important to reduce the room temperature. This can be done by adjusting the thermostat or using fans or air conditioning. By reducing the room temperature, the client's body temperature can gradually decrease, helping to alleviate the symptoms of hyperthermia.
4.
Soon, a 36-year-old male client will be discharged from the hospital after five days due to surgery. Which of the following intervention should be included in home health care instructions of nurses regarding measures to prevent constipation?
Correct Answer
A. The client has to fill a 2-L bottle with water each night and drink it the next day.
Explanation
To prevent constipation, it is important for the client to stay hydrated. Filling a 2-L bottle with water each night and drinking it the next day ensures that the client consumes an adequate amount of water throughout the day. This helps to soften the stool and promote regular bowel movements. Drinking enough water is a simple and effective intervention to prevent constipation in post-surgery patients.
5.
Which of these patients is at most risk for hypomagnesemia?
Correct Answer
B. An old chronic alcoholic
Explanation
An old chronic alcoholic is at most risk for hypomagnesemia because alcoholism can lead to decreased magnesium intake and absorption, increased renal excretion of magnesium, and impaired magnesium utilization. Chronic alcohol consumption can also cause malnutrition, which further increases the risk of magnesium deficiency.
6.
Which of these patients is at most risk for fluid volume deficiency?
Correct Answer
C. Both A & B
Explanation
Both patients A and B are at risk for fluid volume deficiency. Patient A, who has had diarrhea for 2 days, is at risk because diarrhea can lead to excessive fluid loss and dehydration. Patient B, who has continuous nasogastric suction, is at risk because suctioning can remove stomach contents, including gastric secretions and fluids, leading to a decrease in fluid volume. Therefore, both patients are at risk for fluid volume deficiency.
7.
Which patient would have a potassium level = 5.5?
Correct Answer
C. A patient who has Addison's disease.
Explanation
Addison's disease is a condition characterized by a deficiency of cortisol and aldosterone hormones produced by the adrenal glands. One of the functions of aldosterone is to regulate potassium levels in the body. In Addison's disease, the lack of aldosterone can lead to an increase in potassium levels, resulting in hyperkalemia. A potassium level of 5.5 is considered high, and it is likely to be seen in a patient with Addison's disease due to the impaired regulation of potassium by aldosterone.
8.
Which patient is at the highest risk for an electrolyte imbalance?
Correct Answer
B. An 8-month-old having a fever of 102.3 'F and having diarrhea.
Explanation
An 8-month-old having a fever of 102.3 'F and having diarrhea is at the highest risk for an electrolyte imbalance. Fever and diarrhea can lead to excessive fluid loss and dehydration, which can disrupt the balance of electrolytes in the body. Electrolytes such as sodium, potassium, and chloride are essential for maintaining proper cell function and fluid balance. In infants, who have a higher ratio of body surface area to body weight, fluid and electrolyte imbalances can occur more rapidly and have more severe consequences. Therefore, the combination of fever, diarrhea, and young age puts the 8-month-old at the highest risk for an electrolyte imbalance.
9.
Due to burn trauma, there is a 22 years old lady showing facial grimaces at the time of her treatment in the hospital. To reduce the pain caused by cellular injury, which nursing intervention is to be used?
Correct Answer
A. To Administer anti-inflammatory agents as prescribed.
Explanation
The correct answer is to administer anti-inflammatory agents as prescribed. Facial grimaces can be a sign of pain, which is commonly experienced by burn trauma patients. Anti-inflammatory agents can help reduce pain caused by cellular injury and inflammation. Keeping the skin clean and dry is important for preventing infection, but it does not directly address the pain caused by cellular injury. Applying warm packs can help reduce edema, but it does not specifically target the pain caused by cellular injury. Therefore, administering anti-inflammatory agents as prescribed is the most appropriate nursing intervention to reduce the pain in this scenario.
10.
Which intervention is right to add when making a plan of care for a patient experiencing urinary dribbling?
Correct Answer
A. To make the client perform Kegel exercises.
Explanation
Kegel exercises are a suitable intervention for a patient experiencing urinary dribbling because they help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary leakage. Keeping the skin dry and clean is important for maintaining hygiene, but it does not directly address the issue of urinary dribbling. Using pads or diapers can provide temporary containment, but it does not address the underlying problem or help improve bladder control. Therefore, the most appropriate intervention is to make the client perform Kegel exercises.