Nokea
A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?
- A. With a sterile, gloved hand
- B. With a sterile applicator
- C. With sterile 4x4's
- D. By aerosol spray
Correct Answer: C
Rationale: Sulfamylon is applied using sterile 4x4 gauze pads to ensure even coverage and maintain sterility while minimizing pain.
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Which nursing instruction is most appropriate to convey to the client?
- A. Use hypoallergenic or glycerin soap for bathing.
- B. Apply lotion to the affected skin every other day.
- C. Take showers rather than tub baths.
- D. Rub the skin dry after bathing.
Correct Answer: A
Rationale: Hypoallergenic soap minimizes irritation in dry skin.
The nurse must withhold medication administration and notify the physician if which drug is ordered for a client with glaucoma?
- A. Atropine sulfate (Sal-Tropine)
- B. Morphine sulfate (Roxanol)
- C. Magnesium sulfate (Epsom salts)
- D. Ferrous sulfate (Feosol)
Correct Answer: A
Rationale: Atropine can increase intraocular pressure, worsening glaucoma.
Three days ago the client received circumferential, partial, and full-thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to Which physiological response?
- A. Development of a layer of eschar
- B. Loss of elastin and collagen in the tissues
- C. Hypoxia and ischemia of the lungs' alveoli
- D. Fluid overload in the alveoli of the lungs
Correct Answer: A
Rationale: A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness burns but would not be a source of constriction that would prevent lung expansion. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however, restricted breathing (a mechanical process) is more of a risk due to circumferential eschar formation. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is combined with eschar formation.
The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox?
- A. Crops of lesions that have pus and reddened base.
- B. Oval scaling lesions that occur on the legs and arms.
- C. Severe itching of the scalp with tiny eggs visible.
- D. Ringed red lesions on the face, neck, trunk, and extremities.
Correct Answer: A
Rationale: Crops of pustular lesions with a red base are characteristic of chickenpox. Scaling lesions, scalp eggs, and ringed lesions suggest other conditions.
Which nursing instruction is most appropriate before the client leaves the emergency department?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.