Nokea
A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
- A. Administer dopamine as ordered
- B. Apply medical anti-shock trousers
- C. Infuse IV fluids as indicated
- D. Infuse fresh frozen plasma
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
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The nurse is preparing to perform a dressing change on a client with deep partial-thickness and full-thickness burns. Which of the following actions would be inappropriate when caring for this client?
- A. Administer an oral cyclooxygenase-2 (COX-2) inhibitor 30 minutes before the dressing change
- B. Provide a clear explanation to the client about the procedure and how it will be performed
- C. Changing the client's dressing carefully and handling burned areas gently
- D. Let the client watch their favorite television show while dressing change is being performed
Correct Answer: D
Rationale: Watching TV may distract the client but is inappropriate during a painful procedure like a dressing change, as it does not address pain or procedural needs.
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include?
- A. Avoid using alcohol-based hand sanitizer
- B. Use disposable dishes and utensils for all meals
- C. Wear a surgical mask when you are out in public
- D. Keep the wound covered with a dry bandage
Correct Answer: D
Rationale: Keeping the wound covered with a dry bandage prevents the spread of MRSA and protects the wound from further contamination.
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.
The ABCDEs of melanoma identification include which of the following? Select all that apply.
- A. Asymmetry: one half does not match the other half
- B. Birthmark: cafe au lait spot that does not fade
- C. Color: pigmentation is not uniform
- D. Diameter: greater than 6 mm
- E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Correct Answer: A, C, D, E
Rationale: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.