Nokea
The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply.
- A. Place the client in contact isolation.
- B. Administer a corticosteroid IVP.
- C. Assess the client’s pain on a 1-to-10 scale.
- D. Request that the client not have any visitors.
- E. Ensure that only nurses who have had chickenpox care for this client.
Correct Answer: A,C,E
Rationale: Contact isolation, pain assessment, and assigning immune nurses prevent transmission and manage disseminated zoster. Corticosteroids are contraindicated, and visitor bans are excessive.
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The nurse in the long-term care facility must delegate a nursing task to an unlicensed assistive personnel. Which nursing task would be most appropriate to delegate?
- A. Comb the nits out of the client’s hair.
- B. Massage the reddened area on the hip.
- C. Scrape the burrows to remove the scabies mite.
- D. Apply antifungal lotion to the groin area.
Correct Answer: A
Rationale: Combing nits is a non-invasive task within UAP scope. Massaging, scraping, and applying medication require nursing judgment.
The nurse suspects that the client's anxiety is due to fear that nursing care will intensify symptoms. Which nursing intervention is most appropriate to add to the care plan?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, 'What is a xenograft?' Which statement by the nurse would be the best response?
- A. The doctor will graft skin from your back to your leg.'
- B. The skin from a donor will be used to cover your burn.'
- C. The graft will come from an animal, probably a pig.'
- D. I think you should ask your doctor about the graft.'
Correct Answer: C
Rationale: A xenograft uses animal skin (e.g., porcine) for temporary burn coverage. Autografts use the patient’s skin, allografts use donor human skin, and deferring to the doctor avoids education.
The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL X weight in kg X % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? mL of IV fluid (Record your answer as a whole number.)
- A. 4000
Correct Answer: A
Rationale: Use the Parkland formula provided: 4.0 mL at 50 kg = 200 mL; 200 mL × 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn.
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.