Nokea
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin
- B. Wash the skin with water and pat dry
- C. Cover the area with a petroleum gauze
- D. Apply an occlusive dressing to the site
Correct Answer: B
Rationale: Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.
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The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client
- B. Explain to the nurse that there is no risk to the client
- C. Ask the nurse if the chickenpox have scabbed
- D. Ask the nurse if she has ever had the chickenpox
Correct Answer: D
Rationale: Asking if the nurse has had chickenpox determines her immunity, as non-immune nurses risk transmitting varicella to an immunocompromised leukemia patient.
The home health nurse is visiting a 30-year-old with sickle cell disease. Assessment findings include spleenomegaly. What information obtained on the visit would cause the most concern? The client:
- A. Eats fast food daily for lunch
- B. Drinks a beer occasionally
- C. Sometimes feels fatigued
- D. Works as a furniture mover
Correct Answer: D
Rationale: Working as a furniture mover involves heavy physical exertion, which can trigger a sickle cell crisis due to increased oxygen demand and dehydration, posing a significant risk.
Which play activity is best suited to the gross motor skills of the toddler?
- A. Coloring book and crayons
- B. Ball
- C. Building cubes
- D. Swing set
Correct Answer: B
Rationale: Playing with a ball encourages gross motor skills like kicking and throwing, suitable for a toddler's developmental stage.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine should be considered incompatible in a syringe with all other medications
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
- A. There was damage to the hypothalamus.
- B. He has an infection from the abrasions to the head and face.
- C. He will require a cooling blanket to decrease the temperature.
- D. There was damage to the frontal lobe of the brain.
Correct Answer: B
Rationale: Infection from abrasions is the most likely cause of fever post-accident, as it's a common complication.