Nokea
A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.
- A. tetrahydrozoline (Tetryzoline)
- B. isotretinoin (Accutane)
- C. levonorgestrel (Levora)
- D. sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.
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The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers two times per day
- B. Add baby oil to the client's bath water
- C. Apply powder to the client's skin
- D. Suggest a hot-water rinse after bathing
Correct Answer: B
Rationale: Adding baby oil to bath water helps moisturize the skin and alleviate pruritis caused by hepatitis, as it soothes dry, itchy skin without causing irritation.
When administering a capsule that is individually wrapped to a client, when should the wrapping be removed?
- A. When initially obtained from the medicine cart
- B. When placed in the medicine cup
- C. Prior to entering the client's room
- D. At bedside in the client's presence
Correct Answer: D
Rationale: Removing the wrapping at the bedside (D) ensures the client sees the medication, enhancing safety and trust.
The nurse is caring for a client with depression over the recent death of her father from cancer. The client states, 'It's my fault. I should have insisted he get regular checkups instead of letting him put it off.' The nurse responds, 'You feel like it's your fault?' Which therapeutic communication technique is the nurse using?
- A. exploring
- B. reflecting
- C. restating
- D. focusing
Correct Answer: B
Rationale: Reflecting mirrors the client’s feelings, encouraging further expression and exploration of emotions.
The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct Answer: B
Rationale: Applying oxygen is the priority to ensure airway patency and oxygenation in a client with facial and neck burns, which can cause airway compromise.
The nurse is preparing to administer a unit of red blood cells (RBCs) to an anemic client. From starting the infusion (puncturing the blood pack) to completion, infusion of the pack should occur within which time period?
- A. 8 hours
- B. 6 hours
- C. 4 hours
- D. 2 hours
Correct Answer: C
Rationale: RBC transfusions must be completed within 4 hours to minimize bacterial growth and ensure safety.