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Question 1 of 5

A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

Correct Answer: A

Rationale: Elevate the leg on 2 pillows. The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.

Question 2 of 5

The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the development of:

Correct Answer: A

Rationale: Protonix (pantoprazole), a proton pump inhibitor, is prescribed to reduce gastric acid secretion and prevent stress-related mucosal damage, such as Curling's ulcer, which is common in burn patients due to stress and hypoperfusion. Answers B, C, and D are incorrect because Protonix does not directly address myoglobinuria, hyperkalemia, or paralytic ileus.

Question 3 of 5

A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is:

Correct Answer: B

Rationale: The challenge when intervening with clients who might harm themselves is to maintain client safety while facilitating behavior change. Enlisting the client to identify the triggers for self-harm makes the client an active participant in treatment.

Question 4 of 5

A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best response to this request?

Correct Answer: C

Rationale: Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting sodium, fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is appropriate for this age.

Question 5 of 5

A nurse is caring for a newborn who is 2 hours old. Which of the following findings should be reported to the healthcare provider?

Correct Answer: B

Rationale: Jaundice within 24 hours of birth is pathologic, indicating possible hemolytic disease or liver issues, requiring reporting. Heart rate, respiratory rate, and temperature are normal for a newborn.

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