Nokea
The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
- A. 36
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.
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Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?
- A. Transfer the client to the ED for a cardiac work-up.
- B. Inform the client that the nurse can’t see anything.
- C. Administer a nonnarcotic analgesic to the client.
- D. Ask the client if he or she has ever had chickenpox.
Correct Answer: D
Rationale: Burning pain along dermatomes without visible lesions suggests early herpes zoster, linked to prior chickenpox. Cardiac work-up, dismissal, or analgesics are premature.
The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.
On the basis of the nurse's understanding of the etiology of pressure ulcers, the nurse should plan for which intervention to promote the client's skin integrity?
- A. Apply a skin-toughening agent to susceptible areas.
- B. Massage skin areas that remain persistently red.
- C. Keep the head of the bed elevated 30 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning relieves pressure, preventing ulcer progression.
There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?
- A. Use only hand-washing foam when caring for clients with scabies.
- B. Wear gloves when providing hands-on care for a client with scabies.
- C. Wash all linen and clothes in cold water and dry them outside in the sun.
- D. Instruct clients to use plastic eating utensils for meals.
Correct Answer: B
Rationale: Gloves prevent scabies transmission during direct contact. Hand-washing foam is insufficient, hot water washing is needed, and plastic utensils are irrelevant.