saunders psychological

The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.

Acute Resuscitative Rehabilitative

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply.

An irregularly shaped lesion Papule, with a red, central crater

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply.

Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes. Listen in each quadrant for gurgling sounds indicating movement. If 20 sounds are noted within 1 minute, notify the primary health care provider.

A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.

Guttural respiratory sounds Nonproductive cough Hoarse voice

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

Hypotension

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply.

Reports of fatigue Pink mucous membranes

The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply.

The liver is immature. The kidneys are less able to excrete medications

A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breastfeeding the infant and asks the nurse if breastfeeding can be continued. Which response is appropriate?

"Breastfeeding can continue, but your breasts should also be treated with nystatin."

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

Clamp the NG tube for 30 minutes after medication administration. Before medication administration, verify correct placement of tube. Flush the NG tube with saline before and after medication administration. Discontinue the suction from the tube during administration of medication.

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.

Increasing restlessness Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

Use the formula to calculate medication dosages. Formula: Desired --------- × Quantity = mL Available 30 -- × 15 = 11.25 = 11 mL 40

The nurse is caring for a recently admitted client with painful muscle spasms due to a traumatic injury. Besides drug therapy, what are some of the physical measures the nurse expects will be prescribed for this client? Select all that apply.

Whirlpool baths Physical therapy Immobilization of the affected muscle

The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "The reason I need lower salt intake is to reduce fluid retention." 3. "This diet is not a replacement for my antihypertensive medications." 4. "Canned foods are inexpensive and are good to use on a low-sodium diet."

"Canned foods are inexpensive and are good to use on a low-sodium diet."