Nokea
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client’s nutritional status. Which intervention should the nurse implement?
- A. Encourage the client’s family to bring favorite foods.
- B. Provide a low-fat, low-cholesterol diet for the client.
- C. Monitor the client’s weight weekly in the same clothes.
- D. Make a referral to the hospital social worker.
Correct Answer: A
Rationale: Favorite foods increase caloric intake, critical for hypermetabolic burn patients. Low-fat diets are inappropriate, weekly weights are insufficient, and social worker referral is unrelated.
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Which client signs and symptoms indicate contact dermatitis to the nurse?
- A. Erythema and oozing vesicles.
- B. Pustules and nodule formation.
- C. Varicosities and edema.
- D. Telangiectasia and flushing.
Correct Answer: A
Rationale: Erythema and oozing vesicles are hallmark signs of contact dermatitis. Pustules, varicosities, and telangiectasia suggest other conditions.
What is the scientific rationale for placing lift pads under an immobile client?
- A. The pads will absorb any urinary incontinence and contain stool.
- B. The pads will prevent the client from being diaphoretic.
- C. The pads will keep the staff from workplace injuries such as a pulled muscle.
- D. The pads will help prevent friction shearing when repositioning the client.
Correct Answer: D
Rationale: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.
The nurse is planning teaching for the client who is using miconazole cream topically for tinea pedis. Which instruction should the nurse include?
- A. Cover the treated area with an occlusive dressing.
- B. Avoid washing the area prior to applying the cream.
- C. Massage miconazole into the affected area of the foot.
- D. Once symptoms resolve, discontinue using miconazole.
Correct Answer: C
Rationale: Tinea pedis is athlete's foot. Miconazole (Lotrimin AF) should be massaged into the affected area. Occlusive dressings should be avoided to prevent systemic absorption. The area should be washed and dried before application. Miconazole should be continued for the full course of therapy.
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.