Nokea
A nurse is instructing a client about how to apply the topical medication prescribed. Which of the following would the nurse identify as an appropriate way to remove the drug from the container? Select all that apply.
- A. Finger cot
- B. Clean finger
- C. Tongue blade
- D. Gauze pad
- E. Cotton swab
Correct Answer: A,C,D,E
Rationale: Using a finger cot, tongue blade, gauze pad, or cotton swab ensures hygienic application of the topical medication, minimizing contamination and direct skin contact.
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After teaching a group of nursing students about the use of salicylic acid (Duofilm), the instructor determines that the teaching was successful when the students identify which of the following as a contraindication? Select all that apply.
- A. Genital warts
- B. Facial warts
- C. Mucous membrane warts
- D. Moles
- E. Birthmarks
Correct Answer: A,B,C,D,E
Rationale: The use of salicylic acid (Duofilm) is contraindicated in the following situations: on moles, birthmarks, warts with hair growing from them, genital or facial warts, warts on mucous membranes, or infected skin.
A nurse administering collagenase (Santyl) topically to a client must be certain not to use which of the following products that can inactivate the enzymes in collagenase (Santyl)? Select all that apply.
- A. Detergents
- B. Water
- C. Iodine
- D. Silver
- E. Mercury
Correct Answer: A,D,E
Rationale: A nurse administering collagenase (Santyl) topically to a client must be certain not to use detergents or products containing heavy metals, like mercury and silver, which can inactivate the enzymes in collagenase (Santyl).
The primary health care provider has prescribed dexamethasone sodium phosphate for a client being treated for immunologic skin disorder. Assessment of which of the following would lead the nurse to suspect that the client is experiencing an adverse reaction to the drug?
- A. Redness or mild scaling
- B. Allergic contact dermatitis
- C. Dermatitis and irritation
- D. Photosensitivity
Correct Answer: B
Rationale: The nurse should monitor for allergic contact dermatitis as an adverse reaction to dexamethasone sodium phosphate. Redness or mild scaling and photosensitivity are adverse reactions to hexachlorophene. Dermatitis and irritation are adverse reactions to povidone-iodine.
A client is to receive topical masoprocol. The nurse alerts the client to the possibility of which of the following as an adverse reaction? Select all that apply.
- A. Mild pain
- B. Scaling
- C. Numbness
- D. Flu-like syndrome
- E. Dry skin
Correct Answer: B,D,E
Rationale: Adverse reactions related to the topical administration of masoprocol (Actinex) include transient burning sensation, rash, dry skin, scaling, and flu-like syndrome.
When developing the plan of care for a client with a skin lesion requiring topical therapy, which nursing diagnosis would the nurse most likely identify?
- A. Acute Pain
- B. Risk for Infection
- C. Impaired Skin Integrity
- D. Disturbed Body Image
Correct Answer: C
Rationale: Impaired Skin Integrity is the most likely nursing diagnosis due to the presence of a skin lesion requiring topical therapy, as it directly addresses the compromised skin condition.