Sie sind auf Seite 1von 4

1. The nurse is changing a dressing and providing wound care.

Which activity should


she perform first?

a. assess the drainage in the dressing


b. slowly remove the soiled dressing
c. wash hands thoroughly
d. put on latex gloves

2. The client presents with blistering wounds caused by an unknown chemical agent.
How should the nurse intervene?

a. Do nothing until the chemical agent is identified


b. Irrigate the wounds with water
c. Wash the wounds with soap and water and apply a cream
d. Insert a IV catheter and infuse PNSS at 150 cc/hr

3. Which nursing intervention can help a client maintain healthy skin?

a. Keeping the client well hydrated


b. Avoiding bathing the client with mild soap
c. Removing adhesive tape quickly from the skin
d. Recommending wearing tight fitting clothes in warm weather

4. A client received burns to his entire back and left arm. Using rule of nines, the
nurse can calculate that he has sustained burns on what percentage of his body?

a. 1.9%
b. 18%
c. 27%
d. 36%

5. A client has partial thickness burns on both lower extremities and portions of the
trunk. Which IV fluid does the nurse plan to administer first?

a. albumin
b. dextrose 5% in water
c. lactated Ringers solution
d. normal saline solution with 20 meq potassium in 1 liter

6. a client returns from the operating room with a partial-thickness skun graft on his
left arm. The donor tissue was taken from his left hip. This type of graft is known as:

a. autograph
b. heterograph
c. homograph
d. allograph

7. a nurse is assessing a client admitted with deep partial thickness and full thickness
burns on the face, arms and chest. Which finding indicates a potential problem?
a. PaO2 of 80 mmHg
b. Urine output of 20 ml/hr
c. White pulmonary secretions
d. Temp of 38C

8. When planning care for a client with burns on the upper chest, which nursing
diagnosis should take the highest priority?

a. ineffective airway clearance r/t edema of the respiratory passages


b. impaired physical mobility related to disease process
c. disturbed sleep pattern r/t environment
d. risk for infection r/t breaks in the skin

9. a client with a superficial partial thickness burn (sunburn) of the chest, back, face
and arms is seen in the ER. The nurse’s primary concern should be:

a. fluid resuscitation
b. infection
c. body image
d. pain management

10. A nurse is developing a care plan for a client recovering from a serious thermal
burn. After maintaining respirations, the nurse knows that the most important
immediate goal of therapy is:

a. planning for the client’s rehabilitation and discharge


b. providing emotional support to the client and family
c. maintaining the client’s fluid and electrolyte, and acid base balance
d. preserving full range of motion in all affected joints

11. When assessing a client with partial thickness burns over 60% of the body, which
finding should the nurse report immediately?

a. complains of intense thirst


b. moderate to severe pain
c. urine output of 70ml per hour
d. hoarseness of the voice

12. During the acute phase of a burn, a nurse should assess:

a. the client’s lifestyle


b. alcohol use
c. tobacco use
d. circulatory status

13. In a client with burns on the legs, which nursing intervention helps prevents
contractures?

a. applying knee splints


b. elevating the foot of the bed
c. hyperextending the client’s palms
d. performing shoulder range of motion exercise

A client with chronic renal failure has developed faulty red blood cell (RBC)
production. The nurse should monitor this client for:

a. nausea and vomiting


b. dyspnea and cyanosis
c. fatigue and weakness
d. thrush and circumoral palor

A client comes to the emergency room complaining of severe pain in the right flank,
nausea, and vomiting. The physician tentatively diagnoses right urolithiasis. When
planning this client’s care, the nurse should assign the highest priority to which
nursing diagnosis?

a. Acute pain
b. Risk for infection
c. Impaired urinary elimination
d. Imbalanced nutrition: less than body requirements

A nurse is caring for a client in acute renal failure. The nurse should expect
hypertonic glucose, insulin infusions and sodium bicarbonate to be used to treat:

a. hypernatremia
b. hyperkalemia
c. hypokalemia
d. hyponatremia

a nurse is reviewing the client’s fluid intake and output record. Fluid intake and urine
output should relate in which way?

a. fluid intake should be double the urine output


b. fluid intake should be about equal to the urine output
c. fluid intake should be half the urine output
d. fluid intake should be inversely proportional to the urine output

a nurse is caring for a client with acute pyelonephritis. Which nursing intervention is
the most important?

a. administering sitz bath twice per day


b. increasing fluid intake to 3l/day
c. using an indwelling catheter to measure urine output accurately
d. encouraging the client to drink cranberry juice to acidify the urine

a client is admitted for treatment of glomerulonephritis. On initial assessment, the


nurse detects one of the classic signs of acute glomerulonephritis. Such signs include:
a. periorbital edema
b. green-tinged urine
c. moderate to severe hypotension
d. polyuria

a nurse is reviewing a report of a client’s routine urinalysis. Which value requires


further investigation?

a. specific gravity of 1.03


b. urine pH of 3
c. absence of protein
d. absence of glucose

a client with chronic renal failure has a serum potassium level of 6.8 meq/L. what
should the nurse assess first?

a. blood pressue
b. respirations
c. temperature
d. pulse

Which clinical finding should a nurse look for in a client with chronic renal failure?

a. hypotension
b. uremia
c. metabolic alkalosis
d. polycythemia