Nokea
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
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A Hispanic client is admitted to the surgical unit from the emergency department for an appendectomy. The nurse conducts the preoperative preparations and determines that the client has difficulty understanding English. The surgeon needs to obtain the client's informed consent. The nurse course for obtaining the client's informed consent is to:
- A. Have the client call a family member to act as interpreter
- B. Have the client sign the Spanish surgical consent form
- C. Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions
- D. Notify the surgical charge nurse of the situation
Correct Answer: C
Rationale: The surgeon is required to give the client explanations and have questions answered. The nurse has no way of assessing the client's understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and alternatives. A family member cannot be relied on to translate the surgeon's instructions accurately.
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
- A. Dry mucous membranes
- B. Decreased urine output
- C. Sunken fontanelles
- D. Tachycardia
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
You are caring for a hospice client who is at the end of life. Based on this client's signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client?
- A. The client will be free of constipation
- B. The client will remain free of pain and distress
- C. The administration of an antiemetic to prevent vomiting and further dehydration
- D. The administration of an enema to correct the constipation
Correct Answer: B
Rationale: Given the client's comatose state and imminent death, the priority is to maintain comfort. Ensuring the client remains free of pain and distress is the most appropriate outcome, as aggressive interventions like enemas or antiemetics are less relevant in this context.
A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?
- A. Yes, use the inhaler immediately for these symptoms.'
- B. No, this drug is a maintenance drug, not a rescue inhaler.'
- C. Use the inhaler 5 minutes before you exercise to prevent the wheezing.'
- D. This inhaler is for allergic rhinitis, not asthma.'
Correct Answer: B
Rationale: Salmeterol is a long-acting beta-agonist used for asthma maintenance, not for acute symptoms like wheezing during exercise. A rescue inhaler, such as albuterol, is appropriate for acute symptoms.
Sertraline is prescribed for a client in the treatment of depression. Before administering the medication, the nurse reviews the client's record and consults with the primary health care provider when which finding is noted?
- A. Prescribed phenelzine sulfate
- B. A history of diabetes mellitus
- C. A history of myocardial infarction
- D. A history of irritable bowel syndrome
Correct Answer: A
Rationale: Sertraline is a serotonin reuptake inhibitor. Serious potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI). Phenelzine sulfate is an MAOI. MAOIs should be stopped at least 14 days before sertraline therapy. Sertraline should also be stopped at least 14 days before MAOI therapy. The remaining options are not concerns associated with the administration of this medication.