Nokea
A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.
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During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Putting all joints through full range-of-motion twice daily
- B. Massaging the joints briskly with lotion or liniment after bath
- C. Immobilizing the joints in functional position using splints, rolls, and pillows
- D. Applying warm water bottle or heating pads over involved joints
Correct Answer: C
Rationale: Any movement of the joint causes severe pain. Touching or moving the joint causes severe pain. Immobilization in a functional position allows the joint to rest and heal. Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
- A. Dysuria
- B. Epistaxis, hematuria, dysuria
- C. Vertigo, hematuria, ecchymosis
- D. Hematuria, ecchymosis, and epistaxis
Correct Answer: D
Rationale: Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose, indicating bleeding tendencies.
A client with Parkinson's disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect?
- A. The client no longer has intractable tremors.
- B. The client has sufficient production of dopamine.
- C. The client no longer requires any medication.
- D. The client will have increased production of serotonin.
Correct Answer: A
Rationale: Stereotactic surgery, such as deep brain stimulation, aims to reduce symptoms like intractable tremors in Parkinson's disease. It does not directly increase dopamine or serotonin production, nor does it eliminate the need for medication entirely.
The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Contact precautions
- C. Droplet precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.