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A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? 1. 30 degrees 2. 45 degrees 3. 60 degrees 4. 90 degrees

1. 30 degrees

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse? 1."May I take a look at it?" 2."It's time for another graft." 3."Is there any sign of redness?" 4."Let me see whether it is infected."

1."May I take a look at it?"

A client is recovering from full-thickness burns and the nurse provides counselling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching? 1.Cheeseburger and a malted 2.Beef barley soup and orange juice 3.Bacon and tomato sandwich and tea 4.Chicken salad sandwich and soft drink

1.Cheeseburger and a malted

A client who is to receive radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." The best response by the nurse is: 1."It will be no worse than a sunburn." 2."A localized skin reaction usually occurs." 3."Daily application of an emollient will prevent the burn." 4."They may be misinformed."

2."A localized skin reaction usually occurs."

A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is: 1."The procedure will be performed within seven days." 2."Tell me what your primary health care provider said about the graft procedure." 3."The graft procedure will be done as soon as scar formation occurs." 4."It depends on when you are rid of all signs of infection."

2."Tell me what your primary health care provider said about the graft procedure."

The nurse explains to a patient that the virus that causes chickenpox also can cause: 1.Athlete's foot 2.Herpes zoster 3.German measles 4.Infectious hepatitis

2.Herpes zoster

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to: 1.Rinse the mouth three times a day with lemon juice and water 2.Brush the teeth once daily and use dental floss after each meal 3.Vigorously clean the mouth with toothpaste and a firm toothbrush 4.Clean the mouth with a soft toothbrush or a gentle spray

4.Clean the mouth with a soft toothbrush or a gentle spray

The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because the: 1.First client probably will adjust more quickly 2.Second client's incision will take longer to heal 3.Second client is more likely to have phantom limb sensations 4.First and second clients have different occupations

2.Second client's incision will take longer to heal

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1.Eggs." 2.Shellfish." 3.Fried poultry." 4.Cottage cheese."

2.Shellfish."

Before administering preoperative medication to a client, the nurse plans to: 1.Verify the consent 2.Have the client void 3.Check the vital signs 4.Remove the client's dentures

1.Verify the consent

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? (Select all that apply.) 1.Age 2.Anorexia 3.Hemiplegia 4.History of diabetes 5.Urinary incontinence

2.Anorexia 3.Hemiplegia 5.Urinary incontinence

A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include: 1.Low-sodium milk 2.High protein drinks 3.Foods that are low in potassium 4.Ten percent more calories in the form of fats

2.High protein drinks

A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, mottled red, weeping, and edematous. These burns are classified as: 1.Eschar 2.Full-thickness burns 3.Deep partial-thickness burns 4.Superficial partial-thickness burns

3.Deep partial-thickness burns

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1.Cover the cast with plastic wrap until dry 2.Assist with weight bearing when the client ambulates 3.Elevate the affected leg above the level of the heart 4.Insert a finger inside the edges of the cast to check for skin abrasions

3.Elevate the affected leg above the level of the heart

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is: 1.Negligent and can be sued for malpractice 2.Practicing under guidelines of the nurse practice act 3.Protected for these actions, in most states, by Good Samaritan legislation 4.Treating a health problem that can and should be addressed by a primary health care provider

1.Negligent and can be sued for malpractice

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. The nurse concludes that the most probable reason for the noncompliance is that during the exercises: 1.T-tube movement increases 2.The nasogastric tube gets irritating 3.Pain at the incision site increases 4.The bandage on the abdomen is constricting

3.Pain at the incision site increases

A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client? 1.Conveying a positive attitude toward the client 2.Arranging for the client to meet other clients with burns 3.Removing mirrors until the client's physical appearance has improved 4.Reminding family members to avoid comments about the client's appearance

1.Conveying a positive attitude toward the client

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the: 1.Client is able to self-administer pain-relieving drugs as necessary 2.Amount of medication received is determined entirely by the client 3.Amount of drug used for analgesia fluctuates greatly over a given period 4.Self-administration relieves the nurse of monitoring the client for pain relief

1.Client is able to self-administer pain-relieving drugs as necessary

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? (Select all that apply.) 1.Eat foods high in vitamin C. 2.Take your temperature daily. 3.Balance periods of rest and activity. 4.Use a strong soap when washing the skin. 5.Expose the skin to the sun as often as possible

1.Eat foods high in vitamin C. 2.Take your temperature daily. 3.Balance periods of rest and activity.

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is: 1.Exposure to radiation 2.Location of the lesion 3.Self-treatment of lesions 4.Contact with soil contaminants

1.Exposure to radiation

During the first 48 hours after a thermal injury, the nurse should assess the client for: 1.Hypokalemia and hyponatremia 2.Hyperkalemia and hyponatremia 3.Hypokalemia and hypernatremia 4.Hyperkalemia and hypernatremia

2.Hyperkalemia and hyponatremia

A client with scleroderma complains of numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud's phenomenon, a condition commonly associated with scleroderma. The nurse plans to advise the client to: 1.Soak the hands frequently in hot water 2.Keep the hands warm by wearing gloves 3.Rub the hands briskly to increase circulation 4.Take the prescribed anticoagulants to prevent exacerbations

2.Keep the hands warm by wearing gloves

A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first? 1.Notify health care provider 2.Stop infusion 3.Decrease flow rate 4.Reassess in 15 minutes

2.Stop infusion

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? 1.Readiness to discuss the client's deformities 2.Indication of a change in family relations 3.Need for more time to think about the future 4.Beginning realization of implications for the future

4.Beginning realization of implications for the future

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 1.Weight loss 2.Hypoglycemia 3.Decreased blood pressure 4.Inadequate wound healing

4.Inadequate wound healing

A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 1.Radiation 2.Burr holes 3.Dermabrasion 4.Laser technique

4.Laser technique

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will: 1.Leave the skin markings intact 2.Protect the skin from sources of heat 3.Wear soft clothing over the upper body 4.Use an oatmeal-based lotion after each treatment

4.Use an oatmeal-based lotion after each treatment

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? 1.Red 2.Black 3.Green 4.Yellow

4.Yellow