Question

A patient is admitted to the hospital with deep partial thickness burns on his upper chest and face. What is the most important thing for the nurse to monitor with the patient on admission?

Answer 1

Correct Answers:

Respiratory problems

Rationale :

♥️ Burns involving the face and upper chest place the patient at high risk for airway edema and inhalation injury, which can rapidly compromise breathing.

♥️ Heat, smoke, and toxic gases may damage the upper airway and cause progressive swelling, particularly during the first several hours after the injury.

♥️ The nurse should closely assess for hoarseness, stridor, singed nasal hairs, soot around the mouth or nose, dyspnea, and decreasing oxygen saturation.

♥️ Airway swelling can progress quickly and make later intubation extremely difficult, making early recognition and airway management essential.

♥️ Using the ABC priority framework, respiratory compromise takes precedence over wound complications such as infection or contractures.

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Answer 2

Correct Answers:

Avoid spicy foods

Rationale :

🤎 Chemotherapy commonly causes gastrointestinal effects such as nausea, vomiting, mucositis, mouth sores, and altered taste.

🤎 Spicy foods can irritate inflamed oral and gastrointestinal mucosa and increase burning, discomfort, nausea, and diarrhea.

🤎 Clients experiencing mucositis should choose soft, bland, nonacidic foods that are easier to tolerate.

🤎 Small, frequent meals with adequate protein and calories can help maintain nutritional status during treatment.

🤎 Avoiding spicy foods therefore reduces irritation and helps promote adequate nutritional intake and comfort.

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Answer 3

Correct Answers:

Serous otitis media

Rationale :

💜 Air travel causes rapid changes in atmospheric pressure that can interfere with Eustachian tube pressure equalization.

💜 When pressure is not equalized properly, negative pressure can develop in the middle ear and cause fluid accumulation without an acute bacterial infection.

💜 This condition is known as serous otitis media, also called otitis media with effusion.

💜 Affected individuals may experience ear fullness, discomfort, popping, and temporary conductive hearing loss after a flight.

💜 Swallowing, yawning, or other pressure-equalizing techniques can help reduce the effects of barometric pressure changes.

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Answer 4

Correct Answers:

Sending the cells to another site

Rationale :

🌻 The spread of malignant cells from the original tumor to distant tissues is known as metastasis.

🌻 Cancer cells can metastasize through the bloodstream, lymphatic system, or direct extension into surrounding tissues.

🌻 Metastatic disease can impair the function of vital organs such as the brain, liver, lungs, and bones.

🌻 Once cancer has spread to distant sites, treatment becomes significantly more complex and the prognosis often becomes poorer.

🌻 The ability to invade and metastasize is therefore one of the most dangerous characteristics distinguishing malignant tumors from benign tumors.

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Answer 5

Correct Answers:

Ask the patient to smile or raise the eyebrows

Rationale :

🌸 The facial nerve, cranial nerve VII, controls most muscles responsible for facial expression.

🌸 Asking the patient to smile, raise the eyebrows, close the eyes tightly, or puff out the cheeks assesses motor function of this nerve.

🌸 Stapedectomy involves structures within the middle ear that lie near the facial nerve, making postoperative assessment important.

🌸 Facial asymmetry, weakness, or inability to perform these movements can indicate facial nerve injury or dysfunction.

🌸 Comparing movement on both sides of the face helps the nurse determine whether cranial nerve VII function remains intact.

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Answer 6

Correct Answers:

Notify the surgeon

Rationale :

♠️ Mild discomfort or a scratchy sensation can occur after cataract surgery, but sudden severe or sharp eye pain is abnormal.

♠️ Significant postoperative pain may indicate complications such as increased intraocular pressure, hemorrhage, infection, or disruption of the surgical site.

♠️ These complications can threaten vision and require prompt ophthalmologic evaluation.

♠️ The nurse should assess the patient and immediately report the unexpected pain to the surgeon rather than simply masking the symptom.

♠️ Early recognition and intervention can help prevent permanent visual impairment.

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Answer 7

Correct Answers:

In the lower conjunctival sac

Rationale :

🧡 Eye drops should be placed into the lower conjunctival sac, which is formed by gently pulling down the lower eyelid.

🧡 The conjunctival sac allows medication to spread across the eye without directly traumatizing the sensitive corneal surface.

🧡 The dropper tip should remain approximately 1 to 2 cm above the eye and should not touch the lashes, eyelid, or eye surface.

🧡 After instillation, gentle pressure over the nasolacrimal duct may reduce systemic absorption of certain ophthalmic medications.

🧡 Proper placement maximizes medication effectiveness while minimizing injury, contamination, and discomfort.

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Answer 8

Correct Answers:

Assist the patient to ambulate because he gets dizzy

Rationale :

💙 Meclizine is an antihistamine and antiemetic commonly used to treat vertigo, motion sickness, nausea, and dizziness.

💙 Both the underlying vestibular disorder and meclizine itself can cause drowsiness, dizziness, and impaired balance.

💙 These effects increase the patient's risk for falls and injury during ambulation.

💙 The UAP should therefore assist the patient when walking and follow appropriate fall-prevention precautions.

💙 Safe ambulation is particularly important until the nurse determines how strongly the medication affects the patient's alertness and balance.

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Answer 9

Correct Answers:

Foggy Vision

Rationale :

❣️ Open-angle glaucoma usually develops slowly and painlessly as aqueous humor drainage becomes impaired and intraocular pressure gradually increases.

❣️ Clients may describe blurred, hazy, or foggy vision, although the classic progressive deficit is loss of peripheral visual fields.

❣️ Peripheral vision loss can occur so gradually that the client may not recognize the disease until substantial optic nerve damage has occurred.

❣️ Untreated glaucoma can eventually progress to tunnel vision and irreversible blindness because optic nerve injury cannot be reversed.

❣️ Among the listed findings, foggy vision is the most compatible with the gradual visual changes associated with chronic open-angle glaucoma.

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Answer 10

Correct Answers:

Semen

Rationale :

✏️ HIV can be transmitted through specific body fluids containing sufficient concentrations of the virus, including blood, semen, vaginal fluids, rectal fluids, and breast milk.

✏️ Semen can transmit HIV during sexual contact when infected fluid reaches mucous membranes or damaged tissue.

✏️ Transmission risk can be reduced through methods such as correct condom use, HIV testing, antiretroviral therapy, PrEP, and PEP when indicated.

✏️ Casual contact with individuals who have HIV does not transmit the virus because everyday interactions do not involve exposure to infectious body fluids.

✏️ Understanding which fluids transmit HIV helps clients use evidence-based precautions without unnecessary fear or stigma.

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QLexNursing

1 :
A patient is admitted to the hospital with deep partial thickness burns on his upper chest and face. What is the most important thing for the nurse to monitor with the patient on admission?

2 :
You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?

3 :
What type of otitis media can occur after traveling in an airplane?

4 :
Cancer has many characteristics. Which one of the following is the most serious characteristics of cancer?

5 :
After the stapedectomy, what is the most appropriate technique for assessing whether the patient's facial nerve function is intact?

6 :
After cataract surgery a patient complains of sudden sharp pain in the operative eye. What is the most appropriate nursing action?

7 :
The nurse is instructing a patient to instill eyedrops postoperatively. Into which location would the nurse reinforce correct eye drop placement?

8 :
The nurse is reviewing the patient's medication list and sees the patient is taking meclizine. What instructions should be given to the unlicensed assistive personnel?

9 :
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

10 :
A male client comes to the walk-in clinic stating he has just found out he has been exposed to HIV. He wants to know the precise source through which the HIV infection is transmitted, as he wants to take proper precautions. Which of the following body fluids transmits the HIV infection?

QLexNursing

1 : A patient is admitted to the hospital with deep partial thickness burns on his upper chest and face. What is the most important thing for the nurse to monitor with the patient on admission?

2 : You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?

3 : What type of otitis media can occur after traveling in an airplane?

4 : Cancer has many characteristics. Which one of the following is the most serious characteristics of cancer?

5 : After the stapedectomy, what is the most appropriate technique for assessing whether the patient's facial nerve function is intact?

6 : After cataract surgery a patient complains of sudden sharp pain in the operative eye. What is the most appropriate nursing action?

7 : The nurse is instructing a patient to instill eyedrops postoperatively. Into which location would the nurse reinforce correct eye drop placement?

8 : The nurse is reviewing the patient's medication list and sees the patient is taking meclizine. What instructions should be given to the unlicensed assistive personnel?

9 : A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

10 : A male client comes to the walk-in clinic stating he has just found out he has been exposed to HIV. He wants to know the precise source through which the HIV infection is transmitted, as he wants to take proper precautions. Which of the following body fluids transmits the HIV infection?

1 :
A patient is admitted to the hospital with deep partial thickness burns on his upper chest and face. What is the most important thing for the nurse to monitor with the patient on admission?

2 :
You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?

3 :
What type of otitis media can occur after traveling in an airplane?

4 :
Cancer has many characteristics. Which one of the following is the most serious characteristics of cancer?

5 :
After the stapedectomy, what is the most appropriate technique for assessing whether the patient's facial nerve function is intact?

6 :
After cataract surgery a patient complains of sudden sharp pain in the operative eye. What is the most appropriate nursing action?

7 :
The nurse is instructing a patient to instill eyedrops postoperatively. Into which location would the nurse reinforce correct eye drop placement?

8 :
The nurse is reviewing the patient's medication list and sees the patient is taking meclizine. What instructions should be given to the unlicensed assistive personnel?

9 :
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

10 :
A male client comes to the walk-in clinic stating he has just found out he has been exposed to HIV. He wants to know the precise source through which the HIV infection is transmitted, as he wants to take proper precautions. Which of the following body fluids transmits the HIV infection?