Nokea
A patient, age 46, reports to his physician's office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, 'It itches like crazy.' Which type of lesion would the nurse include in her documentation?
- A. Macules
- B. Plaques
- C. Wheals
- D. Vesicles
Correct Answer: C
Rationale: Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border.
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The nurse is preparing the client scheduled for a dermabrasion. Which information should the nurse include while teaching the client?
- A. Erythema will go away within 24 hours.
- B. Do not change the dressing until seen by the HCP.
- C. Stay out of extreme cold or heat situations.
- D. Avoid direct sunlight for three (3) days.
Correct Answer: C
Rationale: Extreme temperatures can impair healing post-dermabrasion.
A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?
- A. Weak positive
- B. Moderately positive
- C. Strong positive
- D. Severely positive
Correct Answer: B
Rationale: Fine blisters, papules, and severe itching indicate a moderately positive reaction.
An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patient's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury?
- A. Lateral collateral ligament injury
- B. Medial collateral ligament injury
- C. Anterior cruciate ligament injury
- D. Posterior cruciate ligament injury
Correct Answer: A
Rationale: When the knee is struck medially, damage may occur to the lateral collateral ligament. If the knee is struck laterally, damage may occur to the medial collateral ligament. The ACL and PCL are not typically injured in this way.
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?
- A. Use a disposable blood pressure cuff to avoid sharing with other clients.
- B. Change gloves between wound care on different parts of the client's body.
- C. Use the closed method of burn wound management for all wound care.
- D. Advocate for proper and consistent handwashing by all members of the staff.
Correct Answer: B
Rationale: Changing gloves between wound care on different body parts prevents autocontamination.
Which data indicates the CombiDerm nonadhesive, sterile, hydrocolloidal dressing is ready to be removed for a client with a stage 3 pressure ulcer?
- A. The exudate begins to pool on the wound surface.
- B. The color of the drainage changes from brown to a yellow-gray.
- C. The HCP must write an order to remove the dressing.
- D. The softened area is approaching the edge of the dressing.
Correct Answer: D
Rationale: CombiDerm is an absorbent hydrocolloidal dressing. It should be removed when the softened area nears the edge, indicating it's saturated. Pooling exudate relates to alginate dressings, color change to Iodosorb gel, and no HCP order is required.