Nokea
It is most appropriate for the nurse to monitor a client for which potential problem?
- A. Infection
- B. Hyperthermia
- C. Depression
- D. Malnutrition
Correct Answer: A
Rationale: Open exposure increases infection risk due to exposed tissue.
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The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client's condition when which observation is noted on assessment?
- A. Decreased swelling in the lower extremity
- B. Strong dorsalis pedis pulses felt bilaterally
- C. Increased erythema in the lower extremity
- D. White blood cell (WBC) count 14,000/mm3
Correct Answer: A
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Observing a decrease in swelling is evidence of improvement. Circulation is not involved with cellulitis, so pedal pulses are unaffected. Increased erythema indicates worsening. A WBC of 14,000/mm3 is elevated, indicating infection.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
- A. The ear feels less warm to the touch.
- B. Ear drainage is thin and watery.
- C. Ear discomfort is relieved.
Correct Answer: C
Rationale: Relief of ear discomfort indicates the infection is responding to treatment.
The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
- A. Instruct the football players to wear tight, snug-fitting jock straps.
- B. Explain the importance of wearing white socks.
- C. Teach the football players to not share brushes or combs.
- D. Discuss the need to dry the groin area thoroughly after bathing.
Correct Answer: D
Rationale: Thorough drying prevents moisture buildup, reducing tinea cruris risk. Tight jock straps trap moisture, socks are irrelevant, and brushes are unrelated.
The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.
The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.