Nokea
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
- A. To place my leg under a heat lamp every 3 hours
- B. Keep a heating pad on the calf of my right leg when I am lying down.
- C. wrap a warm, wet towel around my right calf every 4 hours.
- D. will sit on the side of the tub and soak my right leg two times every day.
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
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A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
- A. Endolymph fluid provides protection to the structures of the inner ear.
- B. Sanguineous fluid provides protection to the structures of the inner ear.
- C. Aqueous humor provides protection to the structures of the inner ear.
- D. Vitreous humor provides protection to the structures of the inner ear.
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.
- B. Large incisions will be made in the eschar to improve circulation.
- C. The procedure involves placing the client into a shower and removing the dead tissue.
- D. Dead tour will be non-surgically removed.
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?
- A. Phlebotomist
- B. Assistive personnel
- C. Senior nursing student
- D. Oncology nurse
Correct Answer: D
Rationale: An oncology nurse is a registered nurse with specialized training and experience in administering blood products, making them qualified to double-check blood labels and patient identification. Phlebotomists, assistive personnel, and senior nursing students lack the required training or authority for this critical safety task.
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
- A. instruct the client to dig their heels into the bed to push themselves upwards.
- B. Assist the client with a trapeze to raise their body while staff assists with repositioning
- C. Have two to three staff members pull the client up in bed when needed.
- D. Elevate the head of the bed 90° for bedridden clients.
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
A nurse is providing dietary teaching to a client who has a new onset of vitamin B12 deficiency. Which of the following foods should the nurse encourage the client to include in their diet?(Select All that Apply)
- A. Steak
- B. Low fat milk
- C. Grilled salmon
- D. Green leafy vegetables
- E. Scrambled eggs
Correct Answer: A,B,C,E
Rationale: Steak, milk, salmon, and eggs are high in vitamin B12, suitable for addressing deficiency. Green leafy vegetables are not significant sources of B12, which is primarily found in animal products.