Nokea
Before the client leaves the emergency department, which nursing instruction is most appropriate?
- 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.
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The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
The nurse is presenting an in-service to participants in a local health fair. Which information regarding the development of skin cancers should the nurse teach?
- A. The fairer the skin, the less the risk of developing skin cancer.
- B. Eating a diet high in fiber helps to minimize the risk of skin cancer development.
- C. Sun exposure at a beach is less dangerous than at a stadium.
- D. The participants should avoid sun exposure in the afternoon hours.
Correct Answer: D
Rationale: Avoiding afternoon sun (10 AM–4 PM) reduces UV exposure, lowering skin cancer risk. Fair skin increases risk, diet is unrelated, and beach/stadium exposure is equivalent.
Which assessment finding is commonly noted when the intraocular pressure (IOP) of a client with angle-closure glaucoma becomes dangerously high?
- A. Spots in the visual field
- B. Severe eye pain
- C. Pinpoint pupils
- D. Bulging eyes
Correct Answer: B
Rationale: Acute angle-closure glaucoma causes severe eye pain due to rapidly elevated IOP.
The nurse is teaching a 24-year-old female with severe cystic acne who is prescribed a systemic retinoic acid drug. Which question is priority?
- A. Are you sexually active?
- B. Are you allergic to vitamin A?
- C. Is your skin dry or sensitive?
- D. Can you take the drug as scheduled?
Correct Answer: A
Rationale: A systemic retinoic acid drug is teratogenic. A sexually active female must be instructed to practice birth control while taking this class of drugs, to avoid pregnancy. Allergy, skin sensitivity, and adherence are important but not the priority.