Nokea
In caring for a stage IV pressure ulcer, the nurse assesses creamy yellow drainage with a necrotic odor. Which type of bacteria most likely causes this exudate?
- A. Proteus
- B. Bacteroides
- C. Staphylococcus
- D. Pseudomonas
Correct Answer: C
Rationale: Creamy yellow drainage is usually caused by Staphylococcus infections. Proteus is associated with a beige discharge having a fishy odor. Brown discharge having a fecal odor is seen in Bacteroides. Pseudomonas-containing wounds produce a green-blue discharge with a fruity odor.
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The nurse provides anticipatory guidance to parents telling them the maximum water temperature for bathing children is which temperature?
- A. 100°F (37.8°C)
- B. 110°F (43.3°C)
- C. 120°F (48.9°C)
- D. 140°F (60°C)
Correct Answer: C
Rationale: The maximum safe water temperature for bathing children is 120°F (48.9°C) to prevent scald burns. Higher temperatures like 140°F can cause severe burns quickly, especially in young children with sensitive skin.
A client is in the health care clinic for complaints of pruritus. Following diagnostic studies, it has been determined that there is not a pathophysiological process causing the pruritus. The nurse prepares instructions for the client to assist in reducing the problem and tells the client to:
- A. use a dehumidifier in the home
- B. ensure that the temperature in the home is high, especially during the winter months
- C. use a cool-mist vaporizer, especially during the winter months
- D. avoid use of skin moisturizers following a bath
Correct Answer: C
Rationale: A cool-mist vaporizer adds moisture to the air, reducing dryness-related pruritus, especially in winter.
The nurse is concerned that a patient is developing a complicated soft tissue bacterial infection. Which assessment finding is most indicative of this condition?
- A. Pain
- B. Fever
- C. Tachycardia
- D. Low blood pressure
Correct Answer: D
Rationale: Low blood pressure suggests systemic involvement (e.g., sepsis) in a complicated infection, beyond localized symptoms like pain or fever.
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
- A. Assess the level of consciousness and pupillary reactions.
- B. Ascertain the time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and bronchi.
- D. Measure abdominal girth and auscultate bowel sounds.
Correct Answer: C
Rationale: Drooling and difficulty swallowing suggest an inhalation injury; auscultating breath sounds assesses airway patency.
Nurse Mary is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it is meant to protect?
- A. Ring or donut
- B. Air mattress
- C. Gel cushion
- D. Foam wedge
Correct Answer: A
Rationale: Ring or donut cushions can increase pressure around the edges, impeding circulation and worsening skin breakdown.