Nokea
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
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A client is confused after receiving morphine for analgesia and repeatedly tries to pull out the intravenous (IV) line in her left arm. Which of the following actions is the best initial solution?
- A. Attempt to camouflage the IV and tie a piece of tubing to the bedrail so the client can pull on that safely.
- B. Apply wrist restraints.
- C. Apply wrist and vest restraints.
- D. Discontinue the IV line and reinsert at a more distant site.
Correct Answer: A
Rationale: Camouflaging the IV and providing a safe alternative (A) is a least-restrictive, non-invasive initial approach to prevent the client from pulling out the IV. Restraints (B, C) should be a last resort, and discontinuing the IV (D) is unnecessary.
The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?
- A. a banana
- B. a bowl of beef broth
- C. a vanilla pudding cup
- D. a cup of strawberries
Correct Answer: A
Rationale: Bananas can cause a cross-reaction in latex-allergic clients due to shared proteins (latex-fruit syndrome). Other items are safe.
A client with increased intracranial pressure is receiving Mannitol and Lasix. The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium accumulation
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Lasix are diuretics that reduce cerebral edema by drawing fluid out of swollen brain cells, decreasing intracranial pressure.
Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
- A. the child with a runny nose
- B. the child who experienced a seizure after the last immunization
- C. the child who experienced a life-threatening allergic reaction after the last immunization
- D. the child with a temperature of 102°F
Correct Answer: A
Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.