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A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the
emergency department. Which action will the nurse take first?
A. Remove the client's clothing.
B. Evaluate whether the client has inhaled smoke.
C. Insert a venous access device in an unaffected arm.
D. Determine the extent of the burns, using the rule of nines. ✔✔B
A client is admitted to the hospital, and benazepril is prescribed for hypertension. Which is an
appropriate nursing action for clients taking this medication?
A.Assess for dizziness.
B.Assess for dark, tarry stools.
C.Administer the medication after meals.
D.Monitor the electroencephalogram (EEG). ✔✔A
A construction worker sustains a puncture wound from a rusty nail and the last immunization for
tetanus in unknown. The primary health care provider prescribes tetanus immune globulin.
Which type of protection does this immunization offer?
,A. Lifelong passive immunity
B. Long-lasting active protection
C. Stimulation of antibody production
D. Immediate passive short-term immunity ✔✔D
A hospice client who has severe pain asks for another dose of oxycodone. Which consideration is
the nurse's primary concern when responding to the client's request?
A. Prevent addiction.
B. Determine why the medication is needed.
C. Provide alternative comfort measures.
D. Reduce the client's pain. ✔✔D
A nurse receives an order to administer cefazolin 2 g/100 mL NS IV every 8 hours. Pharmacy
suggests infusing the cefazolin over 30 minutes. How many milliliters per hour would the nurse
set the IV infusion device? ✔✔200 mL/hr
The nurse has administered sublingual nitroglycerin. Which outcome would the nurse use to
determine the effectiveness of sublingual nitroglycerin?
A.Relief of anginal pain
, B.Improved cardiac output.
C.Decreased blood pressure
D.Ease in respiratory effort ✔✔A
After a subtotal gastrectomy, a client demonstrates signs of dumping syndrome. About 90
minutes after the initial attack, the client reports feeling shaky. Which would the nurse determine
is the cause of the latter effect?
A. A second, more extensive rise in glucose
B. An overwhelmed insulin-adjusting mechanism
C. A distention of the duodenum from an excessive amount of chyme
D. An overproduction of insulin that occurs in response to the rise in blood glucose. ✔✔D
Which type of immunity will clients acquire through immunizations with live or killed vaccines?
A. Natural active immunity
B. Artificial active immunity
C. Natural passive immunity
D. Artificial passive immunity ✔✔B