Question

A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

Answer 1

Correct Answers:

"Read food labels to determine sodium content."

Rationale :

🔶 Hypernatremia results from excess sodium or water deficit; managing intake is the first line of prevention.

🔶 Reading food labels helps clients identify high-sodium items, such as canned or processed foods.

🔶 Clients are often unaware of hidden sodium in condiments, frozen meals, and packaged snacks.

🔶 Educating on label reading promotes self-management and dietary accountability.

🔶 This intervention is specific to monitoring and reducing sodium intake, not general health advice.

🔶 Unlike monitoring weight or pulse, this is a direct action targeting sodium control.

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Answer 2

Correct Answers:

Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.

Rationale :

🔷 Electrical current travels beneath the skin, potentially injuring deep tissues like muscles, nerves, and vessels.

🔷 Surface appearance can be misleading; serious internal injuries may go unnoticed without proper assessment.

🔷 This response educates the client about the hidden severity of electrical burns.

🔷 Nurses must promote understanding that visible damage doesn’t reflect total tissue involvement.

🔷 Prompt evaluation is crucial to detect arrhythmias, compartment syndrome, or rhabdomyolysis.

🔷 Clear explanation enhances patient awareness and encourages timely intervention.

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Answer 3

Correct Answers:

Stage I pressure injury

Rationale :

🟢 Non-blanchable erythema of intact skin is the defining feature of a Stage I pressure injury.

🟢 The skin may feel warmer or cooler, and clients may report pain or discomfort.

🟢 No open wound or skin loss is present at this stage.

🟢 Immediate intervention prevents progression to deeper tissue damage.

🟢 Risk factors include immobility, moisture, and poor nutrition.

🟢 This is the earliest detectable stage and is completely reversible if treated early.

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Answer 4

Correct Answers:

Decontamination of the client

Rationale :

🔴 Gasoline is a chemical irritant and must be removed promptly to prevent further skin and systemic absorption.

🔴 Decontamination is the first priority before other assessments or interventions.

🔴 Delayed removal increases risk of burn progression and toxicity.

🔴 Clothing soaked in gasoline must be removed to reduce exposure.

🔴 Respiratory protection may be needed due to fume inhalation.

🔴 It is a standard emergency protocol in chemical burns.

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Answer 5

Correct Answers:

Keeping the wound clean and non-infected

Rationale :

⚪ Infection prevention is the top priority in wound care to promote healing.

⚪ Cleaning with appropriate solutions helps maintain a healthy wound environment.

⚪ Infection can lead to delayed healing, sepsis, or wound deterioration.

⚪ Priority care involves frequent assessments, proper dressing changes, and sterile technique.

⚪ Negative pressure or nutritional support are adjuncts but do not replace basic wound hygiene.

⚪ Ensuring cleanliness directly affects healing outcomes in pressure injuries.

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Answer 6

Correct Answers:

The blood will be held, and the health care provider will be notified

Rationale :

🟡 A pre-transfusion fever (100°F) may signal existing infection or risk of transfusion reaction.

🟡 The transfusion must be paused until further evaluation by the provider.

🟡 Administering blood during a febrile state can mask or worsen hemolytic reactions.

🟡 Nurses must always report abnormal pre-transfusion vital signs.

🟡 Orders for acetaminophen or other interventions should follow provider assessment.

🟡 Monitoring trends in temperature is essential to ensure transfusion safety.

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Answer 7

Correct Answers:

Be aware of the patient's immunity to chickenpox.

Rationale :

🔶 A prior history of chickenpox suggests natural immunity to varicella-zoster virus.

🔶 Immune individuals are at very low risk of reinfection with chickenpox.

🔶 The nurse must assess exposure risk vs. actual susceptibility.

🔶 Knowing immunity helps prevent unnecessary interventions like immune globulin.

🔶 Immunocompromised or non-immune clients would need prophylactic treatment.

🔶 Educating clients on signs of shingles remains important in older adults.

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Answer 8

Correct Answers:

Shortens the outbreak and lessens the severity of symptoms

Rationale :

🔵 Acyclovir inhibits viral replication, limiting the duration and intensity of HSV outbreaks.

🔵 It reduces pain, itching, and lesion formation during episodes.

🔵 Best outcomes occur when treatment is started at the first sign of symptoms.

🔵 The virus is not eradicated, but controlled more effectively.

🔵 Acyclovir is part of episodic or suppressive therapy depending on frequency.

🔵 It lowers the chance of complications and secondary infections.

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Answer 9

Correct Answers:

Urine output is greater than 0.5 mL/kg/hr

Rationale :

⚫ Urine output is the most sensitive indicator of effective fluid resuscitation in burns.

⚫ Adequate output reflects good renal perfusion and tissue hydration.

⚫ Monitoring urine helps assess for hypovolemia or fluid overload.

⚫ Blood pressure and heart rate may lag behind true volume status.

⚫ Urine targets are typically 0.5–1 mL/kg/hr in adults.

⚫ Burn patients require frequent I&O charting during the resuscitation phase.

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Answer 10

Correct Answers:

Morbidly obese patient
A woman who smokes and takes oral contraceptives or smoke
Wheelchair-bound patient
Patient who underwent a prolonged surgical procedure

Rationale :

🟣Morbid obesity increases VTE risk due to immobility and venous stasis.

🟣Smoking + oral contraceptives compound clotting risk via estrogen and vascular damage.

🟣Wheelchair-bound status adds to venous pooling from immobility.

🟣Prolonged surgery increases risk through inactivity, vessel injury, and stress response.

🟣 Early ambulation, compression devices, and anticoagulants reduce VTE incidence.

🟣 Upper limb fractures are less associated with deep vein thrombosis.

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QLexNursing

1 :
A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

2 :
A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

3 :
A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

4 :
A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

5 :
A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

6 :
The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

7 :
A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

8 :
A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

9 :
A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

10 :
A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

QLexNursing

1 : A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

2 : A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

3 : A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

4 : A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

5 : A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

6 : The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

7 : A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

8 : A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

9 : A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

10 : A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

1 :
A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

2 :
A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

3 :
A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

4 :
A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

5 :
A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

6 :
The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

7 :
A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

8 :
A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

9 :
A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

10 :
A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)