Nokea
A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
- A. A semi-private room with a noninfectious client
- B. A room with a postoperative client
- C. An isolation room
- D. A private room with a private bath
Correct Answer: C
Rationale: An isolation room is necessary to reduce the risk of infection, a major complication in burn clients due to compromised skin barriers.
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Which action is most appropriate to include in the postoperative care plan when a client has skin grafts?
- A. Minimize movement to prevent graft disruption.
- B. Change the dressing over the graft every 8 hours.
- C. Reinforce the graft dressing if drainage occurs.
- D. Apply wet soaks to the graft every 4 hours.
Correct Answer: A
Rationale: Minimizing movement ensures graft adherence and healing.
Which statement would the nurse expect the client to report when looking at an object without wearing corrective glasses or contact lenses?
- A. I see near objects more clearly.
- B. I see a blurry area in front of me.
- C. I see far objects more clearly.
- D. I see two of the same object.
Correct Answer: B
Rationale: Astigmatism causes blurry or distorted vision due to irregular corneal curvature.
The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first?
- A. Refer the client to an HCP for a biopsy of the area.
- B. Assess the lesion for size, color, and symmetry.
- C. Discuss end-of-life decisions with the client.
- D. Report the sexually transmitted illness to the health department.
Correct Answer: B
Rationale: Assessing the lesion provides data for suspected Kaposi’s sarcoma, common in AIDS. Biopsy referral, end-of-life discussions, and reporting are secondary.
When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?
- A. Lower torso
- B. Upper part of the body
- C. Hands and feet
- D. Perineum
Correct Answer: B
Rationale: Burns to the upper body, including the chest and face, increase the risk of respiratory complications, such as airway obstruction or inhalation injury, which are life-threatening.