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Questions 157

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Question 1 of 5

An adult is admitted with deep partialthickness and full-thickness burns on both lower legs, the anterior chest, and the anterior and posterior aspects of the right arm. Using the Rule of Nines, calculate the percentage of body burned.

Correct Answer: B

Rationale: Using the Rule of Nines: both lower legs (18%), anterior chest (9%), right arm anterior and posterior (9%) = 18 + 9 + 9 = 36% total body surface area burned.

Question 2 of 5

The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?

Correct Answer: D

Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.

Question 3 of 5

The treatment protocol for a client with acute lymphatic leukemia includes Orasone (prednisone), Trexall (methotrexate), and Zantac (ranitidine). The purpose of Zantac is to:

Correct Answer: D

Rationale: Zantac (ranitidine) prevents gastric irritation and ulcers, a common side effect of prednisone. It does not affect pancreatic enzymes, methotrexate efficacy, or peristalsis.

Question 4 of 5

Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?

Correct Answer: B

Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.

Question 5 of 5

Which assessment is most essential before administering digoxin to an adult?

Correct Answer: B

Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.

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