Nokea
Shortly before each debridement, which nursing intervention is essential?
- A. Keeping the client in a fasting state
- B. Witnessing a signed consent form
- C. Administering a prescribed analgesic
- D. Weighing the client on a bed scale
Correct Answer: C
Rationale: Analgesics are essential to manage pain during debridement.
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The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this client?
- A. Penicillin
- B. Acyclovir
- C. Tetracycline
- D. Benadryl
Correct Answer: B
Rationale: Acyclovir is the antiviral medication used to treat herpes zoster (shingles), reducing viral replication and symptom duration.
When the nurse reviews the client's health history, which symptom is directly related to the development of cataracts?
- A. Gradual loss of vision
- B. Feeling of fullness within the eye
- C. Ocular pain or discomfort
- D. Flashes of light
Correct Answer: A
Rationale: Cataracts cause a gradual loss of vision due to lens opacity.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
- A. Turn on soft music and shut the blinds.
- B. Apply warm, moist heat to the lesions.
- C. Notify the HCP for more pain medication.
- D. Encourage the client to ambulate with assistance.
Correct Answer: A
Rationale: Soft music and dim lighting provide nonpharmacologic pain relief for herpes zoster. Heat may worsen pain, more medication is premature, and ambulation is unrelated.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.