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NCLEX-RN Exam Questions - Part 17
1. The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
A) Neosporin sulfate
B) Mafenide acetate
C) Silver sulfadiazine
D) Povidone-iodine
2. The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
A) Decreases hypertrophic scar formation
B) Assists with ambulation
C) Covers burn scars and decreases the psychological impact during recovery
D) Increases venous return and cardiac output by normalizing fluid status
3. A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?
A) Celery
B) Potatoes
C) Tomatoes
D) Liver
4. Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
A) Distant breath sounds
B) Increased heart sounds
C) Decreased anteroposterior chest diameter
D) Collapsed neck veins
5. The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
A) Increase his nasal O2 to 6 L/min
B) Place him in a lateral Sims - position
C) Encourage pursed-lip breathing
D) Have him breathe into a paper bag
A) Neosporin sulfate
B) Mafenide acetate
C) Silver sulfadiazine
D) Povidone-iodine
2. The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
A) Decreases hypertrophic scar formation
B) Assists with ambulation
C) Covers burn scars and decreases the psychological impact during recovery
D) Increases venous return and cardiac output by normalizing fluid status
3. A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?
A) Celery
B) Potatoes
C) Tomatoes
D) Liver
4. Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
A) Distant breath sounds
B) Increased heart sounds
C) Decreased anteroposterior chest diameter
D) Collapsed neck veins
5. The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
A) Increase his nasal O2 to 6 L/min
B) Place him in a lateral Sims - position
C) Encourage pursed-lip breathing
D) Have him breathe into a paper bag
1. Right Answer: B
Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function.
2. Right Answer: A
Explanation: (A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
3. Right Answer: B
Explanation: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.
4. Right Answer: A
Explanation: (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.
5. Right Answer: C
Explanation: (A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.
Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function.
2. Right Answer: A
Explanation: (A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
3. Right Answer: B
Explanation: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.
4. Right Answer: A
Explanation: (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.
5. Right Answer: C
Explanation: (A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.
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