Nokea
The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.
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The client with the condition illustrated is prescribed adapalene topical daily to the affected areas. Which information should the nurse exclude when planning client education?
- A. The client has acne vulgaris, an inflammatory disease involving the sebaceous glands of the skin characterized by papules or pustules or comedones.
- B. Adapalene should be applied once daily in the evening.
- C. Exposing the back to the sun after adapalene (Differin) is applied.
- D. Only a thin film of adapalene should be applied.
Correct Answer: C
Rationale: The nurse should exclude exposing the back to the sun after adapalene (Differin) is applied. This increases the risk for sunburn. Adapalene should also not be applied to sunburned areas. The client has acne vulgaris. Adapalene should be applied once daily in the evening with a thin film.
The nurse writes the client problem of 'acute pain and itching secondary to bacterial skin lesions.' Which interventions should be included in the care plan? Select all that apply.
- A. Keep humidity at less than 20%.
- B. Maintain a cool environment.
- C. Use a mild soap for sensitive skin.
- D. Keep lesions covered at all times.
- E. Apply skin lotion after bathing.
Correct Answer: B,C,E
Rationale: Cool environment, mild soap, and lotion reduce itching and pain in bacterial lesions. Low humidity worsens dryness, and constant coverage may trap moisture, promoting infection.
Which immediate nursing interventions are appropriate for this client? Select all that apply.
- A. Place ice packs on the burned areas.
- B. Pour normal saline over the burned areas before dressing care.
- C. Begin an I.V. infusion of lactated Ringer's solution.
- D. Administer a tetanus injection.
- E. Administer pain medication.
- F. Administer oxygen therapy.
Correct Answer: B,C,D,E,F
Rationale: Ice packs can worsen tissue damage; other interventions address fluid loss, infection, pain, and oxygenation.
The nurse is caring for an elderly female client preoperative for facial reconstruction. Which client problem should the nurse include in the preoperative plan of care?
- A. Loss of self-esteem.
- B. Alteration in comfort.
- C. Ineffective airway clearance.
- D. Impaired communication.
Correct Answer: A
Rationale: Facial reconstruction may impact self-esteem due to appearance concerns. Comfort, airway, and communication are less relevant preoperatively.
The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?
- A. Padding the client's sacrum and heels
- B. Obtaining an alternating air pressure mattress
- C. Using a lifting device when turning the client
- D. Keeping the head of bed lower than 30 degrees
Correct Answer: D
Rationale: Keeping the HOB higher than 30 degrees increases the shearing forces to the shoulders, sacrum, and heels. Padding and air mattresses reduce tissue pressure but not shearing forces. Using a lift sheet helps reduce friction but not shearing forces.