Nokea
Silver nitrate dressings are applied to burns on an adult. What should be included in the nursing care plan?
- A. Change the dressings every two hours.
- B. Keep the dressings wet.
- C. Carefully monitor fluid intake.
- D. Observe for black discoloration.
Correct Answer: B
Rationale: Silver nitrate dressings must be kept wet to maintain their antibacterial effectiveness and prevent tissue damage.
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Of the following information provided by the client to the nurse, which factor is most likely to cause a retinal detachment?
- A. The client is younger than age 40.
- B. The client fell and struck the head.
- C. The client has multiple allergies.
- D. The client is being treated for glaucoma.
Correct Answer: B
Rationale: Trauma, such as a head injury, is a common cause of retinal detachment.
Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis?
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: C
Rationale: IgE mediates allergic reactions, elevated in contact dermatitis. IgA, IgD, and IgG are less relevant.
The nurse in a dermatology clinic is taking the history of a client. Which questions should the nurse ask the client? Select all that apply.
- A. When did you first notice the skin problem?
- B. What cosmetics or skin products do you use?
- C. Have you experienced any loss of sensation?
- D. What is your current and previous occupation?
- E. Do you experience any itching, burning, or tingling?
Correct Answer: A,B,C,D,E
Rationale: All listed questions assess onset, triggers, symptoms, and occupational exposures, critical for dermatologic history.
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
- A. Estimate the amount of burned area using the rule of nines.
- B. Insert two (2) 18-gauge catheters and begin fluid replacement.
- C. Apply sterile saline dressings to the burned areas.
- D. Determine the client’s airway status.
- E. Administer morphine sulfate, IV.
Correct Answer: D,B,E,A,C
Rationale: Priority: 1) Airway status (ABCs); 2) IV catheters/fluids (prevent shock); 3) Morphine (pain control); 4) Rule of nines (guide resuscitation); 5) Sterile dressings (infection prevention).
Which common ailment should the nurse instruct the client who underwent a stapedectomy to immediately report to the physician?
- A. The common cold
- B. A sore throat
- C. A productive cough
- D. Conjunctivitis
Correct Answer: A
Rationale: A cold can lead to middle ear pressure changes, risking surgical complications.