Mr. Kawasaki, a 23-year old industrial worker, was burned severely in an industrial accident. He has second degree burns on his right leg and arm, and on his left leg. He has third degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of burn as:

Correct Answer: C

Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body. Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based

Correct Answer: D

Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia. 2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate. 3. It boosts his confidence and motivation, leading to improved verbal communication over time. Summary of why other choices are incorrect: B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication. C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia. D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.

Correct Answer: C

Rationale: The correct answer is C: Night sweats. In Hodgkin's disease category B, the presence of night sweats signifies more advanced disease and higher tumor burden. Night sweats are a B-symptom, along with fever and weight loss, indicating systemic symptoms. Anemia (choice B) and thrombocytopenia (choice D) are not specific to Hodgkin's disease category B and can be present in various other conditions. Fever (choice A) is not exclusive to Hodgkin's disease category B and can occur in many infections and inflammatory conditions. Night sweats are specifically associated with Hodgkin's disease and are a key indicator of disease severity in this context.

Correct Answer: A

Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.

Correct Answer: D

Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.

Correct Answer: D

Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.

Correct Answer: C

Rationale: The correct answer is C because assessing the patient's pain level is the priority when caring for a patient with a brain tumor about to begin radiation treatments. Pain management is crucial in providing comfort and ensuring the patient's well-being during treatment. Teaching the patient about what to expect and addressing any pain promptly are essential steps in delivering effective care. Padding the side rails (choice A) is important for patient safety, but it is not the priority in this situation. Isolating the patient (choice D) is unnecessary unless there is a specific medical indication. Teaching the patient what to expect (choice B) is important but assessing and managing pain take precedence to ensure the patient's comfort and safety during treatment.