Nokea
How can the nurse best relieve the client's fear and anxiety?
- A. Recline the client so as to avoid seeing the blood.
- B. Give the client a popular magazine to read.
- C. Replace the client's clothing with a hospital gown.
- D. Cover the client's eyes with a bath towel.
Correct Answer: C
Rationale: Changing stained clothing reduces visual reminders of bleeding, easing fear.
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The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?
- A. The client complains of pain when the medication is administered.
- B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
- C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
- D. The client is able to perform active range-of-motion exercises.
Correct Answer: C
Rationale: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- A. Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- B. Cover the area with an occlusive dressing after applying a steroid cream.
- C. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- D. Teach the client the risks and hazards of implanted radiation therapy.
Correct Answer: B
Rationale: Occlusive dressings with steroids enhance absorption, treating psoriasis. Mycostatin is for fungal infections, acyclovir is for viral infections, and radiation is irrelevant.
The nurse is planning teaching for the client who is using miconazole cream topically for tinea pedis. Which instruction should the nurse include?
- A. Cover the treated area with an occlusive dressing.
- B. Avoid washing the area prior to applying the cream.
- C. Massage miconazole into the affected area of the foot.
- D. Once symptoms resolve, discontinue using miconazole.
Correct Answer: C
Rationale: Tinea pedis is athlete's foot. Miconazole (Lotrimin AF) should be massaged into the affected area. Occlusive dressings should be avoided to prevent systemic absorption. The area should be washed and dried before application. Miconazole should be continued for the full course of therapy.
Which client signs and symptoms indicate contact dermatitis to the nurse?
- A. Erythema and oozing vesicles.
- B. Pustules and nodule formation.
- C. Varicosities and edema.
- D. Telangiectasia and flushing.
Correct Answer: A
Rationale: Erythema and oozing vesicles are hallmark signs of contact dermatitis. Pustules, varicosities, and telangiectasia suggest other conditions.