Nokea
Sue has a mild dermatitis rash and asks for advice. You respond by saying
- A. Wash the area with an antiseptic soap frequently to keep the area clean.
- B. Use an antifungal ointment.
- C. Use talcum powder to soothe the inflamed skin.
- D. Use a mild steroidal cream.
Correct Answer: D
Rationale: Steroidal creams reduce inflammation in dermatitis.
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In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
What should a client with seasonal affective disorder be taught upon discharge?
- A. Use heavy drapes rather than translucent curtains or shades
- B. Jog after sundown and before sunup
- C. Avoid the use of eyeglasses or contact lenses that are coated to shield ultraviolet radiation
- D. Take brief walks outside around midnight without sunglasses
Correct Answer: C
Rationale: Maximizing exposure to natural light helps alleviate symptoms of seasonal affective disorder.
A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Continue to monitor the client as this is an expected finding.
- B. Add more water to the suction control chamber of the drainage system.
- C. Verify that the suction regulator is on and check the tubing for leaks.
- D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Correct Answer: C
Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
1. Lack of bubbling in the suction control chamber indicates suction may not be working.
2. Checking the suction regulator ensures it is on and at the correct level for proper drainage.
3. Checking tubing for leaks ensures the system is intact and functioning properly.
4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery.
Summary:
- Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction.
- Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause.
- Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.
What volume of fluid loss causes marked deterioration in hypovolemic shock?
- A. 30% to 40% (1500 mL to 2000 mL)
- B. 15% to 30% (750 mL to 1500 mL)
- C. 10% to 15% (500 mL to 750 mL)
- D. More than 40% (more than 2000 mL)
Correct Answer: B
Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.
Which nursing actions would demonstrate the nurse’s understanding of the concept of providing safe care without using restraints (select all that apply)?
- A. Placing patients with fall risk in low beds.
- B. Making hourly rounds on patients to assess for pain and toileting needs.
- C. Applying a jacket vest loosely so the patient can turn but cannot climb out of bed.
- D. Placing a disruptive patient near the nurses’ station in a chair with a seat belt.
Correct Answer: B
Rationale: Low beds, frequent checks, and strategic placement reduce risks without resorting to physical restraints.