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Questions 148

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Question 1 of 5

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Correct Answer: A

Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.

Question 2 of 5

The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification

Question 3 of 5

A client confides in the nurse that a close friend recently died from pancreatic cancer. The client asks what the risk factors are for pancreatic cancer. The nurse should respond with

Correct Answer: D

Rationale: Cigarette smoking is a well-established risk factor for pancreatic cancer, increasing risk through carcinogenic exposure.

Question 4 of 5

The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.

Correct Answer: B, D, E

Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.

Question 5 of 5

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Correct Answer: A

Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.

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