Nokea
A nurse can assess cyanosis in a dark-skinned patient by assessing the color of which body part?
- A. abdomen
- B. sclera.
- C. lips and mucous membranes.
- D. soles of the feet.
Correct Answer: C
Rationale: Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes. Assessing the abdomen, sclera or soles of the feet will not be as accurate as the lips and mucous membranes.
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The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?
- A. Transport victim to hospital.
- B. Cover victim with clean cloth or sheet.
- C. Stop, drop, and roll.
- D. Remove all nonadherent clothing and jewelry.
Correct Answer: C
Rationale: The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital.
The nurse will provide which instruction regarding reducing the risk factors for melanoma?
- A. Avoid exposure to the sun and use protective measures when exposure occurs.
- B. Have all nevi removed.
- C. Watch for changes in moles, especially on the back.
- D. Use a sun lamp for tanning.
Correct Answer: A
Rationale: Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Having all nevi removed is impractical. Watching for changes in moles does not reduce risk factors; it allows for early detection. Sun lamps are just as damaging as the sun.
Which will the nurse dressing a necrotic pressure injury with a minimal exudate most likely use?
- A. Hydrocolloid dressing
- B. Alginate dressing
- C. Hydrofiber dressing
- D. Transparent film
Correct Answer: A
Rationale: Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.
Which is a nursing intervention and patient teaching item for the treatment of head lice and scabies?
- A. Clothing, linens, and bath articles thoroughly cleaned in hot water
- B. Stress nature and transmission of the disease
- C. Special carbohydrate diet to promote healing
- D. Complete isolation from the public
- E. removal of pets from the home
Correct Answer: A,B
Rationale: Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. It is not necessary to remove pets from the home.
Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
- A. Curling ulcer
- B. Paralytic ileus
- C. Ruptured colon
- D. Gastritis
Correct Answer: A
Rationale: Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. Paralytic ileus involves the small intestine becoming immobile, characterized by absent bowel sounds. A ruptured colon would cause internal bleeding, and possibly rectal bleeding. Gastritis would not cause bright red bleeding.