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A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?
- A. Administer an antibiotic medication.
- B. Cleanse skin eruptions with povidone-iodine.
- C. Avoid over-the-counter topical ointments.
- D. Place disposable thermometers in the client's room.
Correct Answer: C
Rationale: Avoiding OTC ointments prevents irritation or delayed healing in herpes simplex outbreaks.
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The client is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy.
A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
- A. Massage the affected extremity every 4 hr.
- B. Initiate bed rest.
- C. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- D. Administer aspirin for pain.
Correct Answer: B
Rationale: Bed rest prevents dislodging the clot while on anticoagulants.
The son of a client who has Alzheimer's disease and mild hypertension.
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease and mild hypertension. Which of the following responses should the nurse make?
- A. You owe it to your mother to take care of her now that she needs you.
- B. Let me give you some information about respite care for your mother.
- C. I think you should find other family members who could help your mother.
- D. You should think about placing your mother in a long-term care facility.
Correct Answer: B
Rationale: Respite care information supports the caregiver's well-being.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Persistent uterine contractions
- B. Increased fetal movement
- C. Rigid abdomen
- D. Bright red vaginal bleeding
Correct Answer: D
Rationale: Bright red vaginal bleeding is characteristic of placenta previa.
A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?
- A. I should use my inhaler when I have an asthma attack.
- B. I will rinse my mouth and gargle with water after each inhaler treatment.
- C. I will take my inhaler treatment before each meal and at bedtime.
- D. I should use my inhaler before exercising.
Correct Answer: B
Rationale: Rinsing the mouth after budesonide (a corticosteroid) prevents oral thrush, indicating understanding.