Nokea
After instilling medication into the client's ear, which nursing instruction is most appropriate?
- A. Keep your head tilted for 5 minutes.
- B. Pack a cotton ball tightly in your ear.
- C. Do not blow your nose for at least 1 hour.
- D. Wipe the excess medication from the ear.
Correct Answer: A
Rationale: Keeping the head tilted allows the medication to stay in contact with the ear canal.
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The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.
The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply.
- A. Place the client in contact isolation.
- B. Administer a corticosteroid IVP.
- C. Assess the client’s pain on a 1-to-10 scale.
- D. Request that the client not have any visitors.
- E. Ensure that only nurses who have had chickenpox care for this client.
Correct Answer: A,C,E
Rationale: Contact isolation, pain assessment, and assigning immune nurses prevent transmission and manage disseminated zoster. Corticosteroids are contraindicated, and visitor bans are excessive.
Which of the parent's statements indicates a need for further teaching?
- A. Lice are gone if I don't see any one day after treatment.
- B. I've washed all the bed linens in soap, hot water, and bleach.
- C. None of my children shares each other's combs or brushes.
- D. Once there is an outbreak, all students should be inspected.
Correct Answer: A
Rationale: Lice treatment requires follow-up to ensure all nits are eradicated.
When planning the child's discharge, what nursing instruction is most appropriate for the nurse to provide the parent concerning the cotton ball in the client's ear canal?
- A. Leave the cotton ball in place until it is saturated.
- B. Keep the cotton ball placed loosely within the ear canal.
- C. Remove the cotton ball in peroxide before insertion.
- D. Remove the cotton ball when the cotton becomes dry.
Correct Answer: B
Rationale: A loosely placed cotton ball protects the ear without causing pressure.
The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client?
- A. Immobilization of the graft site
- B. Weight-bearing exercises to the graft site
- C. Assist client out of bed as much as tolerated
- D. Maintain right leg in a dependent position
Correct Answer: A
Rationale: The graft must be immobilized so that it can remain in place and be able to revascularize. The client cannot place weight on the graft site. Bearing weight causes trauma. A dependent position impairs circulation and may cause further tissue injury.