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  1. Home
  2. NCLEX Certification
  3. NCLEX-PN Exam
  4. NCLEX.NCLEX-PN.v2023-10-03.q213 Dumps
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Question 21

When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

Correct Answer: A
Explanation/Reference:
Explanation:
Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution. Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns. Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns. Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns. Health Promotion and Maintenance
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Question 22

A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

Correct Answer: C
Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance
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Question 23

When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

Correct Answer: C
Section: Physiological Integrity
Explanation:
The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute.
Higher flow rates must be delivered by mask.
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Question 24

Client room environments should include __________.

Correct Answer: B
Section: Physiological Integrity
Explanation:
Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby.
All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
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Question 25

A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD).
Oxygen is delivered at 1 L/min per nasal cannula.
The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?

Correct Answer: A
Section: Physiological Integrity
Explanation:
COPD clients are compensating for low oxygen and high carbon dioxide levels.
Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia.
Increasing the level of oxygen decreases the stimulus to breathe.
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