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A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
- A. Assess the level of consciousness and pupillary reactions.
- B. Ascertain the time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and bronchi.
- D. Measure abdominal girth and auscultate bowel sounds.
Correct Answer: C
Rationale: Drooling and difficulty swallowing suggest an inhalation injury; auscultating breath sounds assesses airway patency.
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In caring for a stage IV pressure ulcer, the nurse assesses creamy yellow drainage with a necrotic odor. Which type of bacteria most likely causes this exudate?
- A. Proteus
- B. Bacteroides
- C. Staphylococcus
- D. Pseudomonas
Correct Answer: C
Rationale: Creamy yellow drainage is usually caused by Staphylococcus infections. Proteus is associated with a beige discharge having a fishy odor. Brown discharge having a fecal odor is seen in Bacteroides. Pseudomonas-containing wounds produce a green-blue discharge with a fruity odor.
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?
- A. Come to the emergency department.
- B. Apply calamine lotion immediately to the exposed skin areas.
- C. Take a shower immediately, lathering and rinsing several times.
- D. It is not necessary to do anything if you cannot see anything on your skin.
Correct Answer: C
Rationale: Washing off the urushiol oil from poison ivy prevents the rash from developing.
The nurse has many teaching responsibilities preoperatively. From the following list, which topic would be within the nurse's scope to provide instructions about preoperatively?
- A. Diaphragmatic breathing, positioning/turning in bed, and coughing exercises
- B. Potential risks of the surgery
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Measures to ensure respiratory, circulatory, and gastrointestinal functioning (like diaphragmatic breathing, positioning, and coughing exercises) are important for the nurse to teach preoperatively. The physician discusses potential risks during informed consent.
The nurse notes that a male patient is bald. What is the status of the hair follicles on the head of this patient?
- A. Dead
- B. In the resting phase
- C. Awaiting keratinization
- D. Pausing in the growth cycle
Correct Answer: B
Rationale: Baldness occurs when hair follicles enter a prolonged resting phase and do not progress to the growth phase.
The nurse is collecting data during a routine clinic visit. The client reports she has experienced bleeding between her menstrual periods. What initial action by the nurse is most appropriate?
- A. Determine the timing of the bleeding episodes.
- B. Determine the amount of the bleeding episodes.
- C. Assess for the presence of sexually transmitted infections.
- D. Review the length of the client's normal menstrual cycles.
Correct Answer: A
Rationale: Timing of bleeding helps identify causes (e.g., midcycle ovulation). Amount and other assessments follow this initial step.