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The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
- A. A 22-gauge intravenous line with normal saline infusing.
- B. Wounds covered with moist sterile dressings.
- C. No intravenous pain medication.
- D. Ensure adequate peripheral circulation to both feet.
Correct Answer: D
Rationale: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
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The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview?
- A. Do you live in an area where animals roam the street?'
- B. Have you been working in your garden lately?'
- C. Have you been deer hunting in the last week?'
- D. Do you use sunscreen when you are outside?'
Correct Answer: C
Rationale: A bullseye rash and systemic symptoms suggest Lyme disease, linked to tick exposure during activities like deer hunting. Animal roaming, gardening, and sunscreen are less relevant.
The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation? Select all that apply.
- A. Burning sensation is felt in the affected arm.
- B. Pain reduced from 5 to 2 on a 0 to 10 scale.
- C. Irrigation runoff solution pH measures 7.0.
- D. Absence of pain in the arm with the acid burn.
- E. Affected arm skin surface pH measures 4.8.
Correct Answer: A,B,E
Rationale: The presence of a burning sensation may indicate that some acid remains on the skin and additional irrigation is needed. The presence of pain, even though reduced, could indicate that not all of the acid has been removed from the skin. A pH of 4.8 is acidic and indicates there is still acid residue that needs to be removed. A pH of 7 indicates a nonacidic status, which would be a positive finding. The absence of pain would indicate that all acid was removed before it could damage the skin.
The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
- A. Instruct the football players to wear tight, snug-fitting jock straps.
- B. Explain the importance of wearing white socks.
- C. Teach the football players to not share brushes or combs.
- D. Discuss the need to dry the groin area thoroughly after bathing.
Correct Answer: D
Rationale: Thorough drying prevents moisture buildup, reducing tinea cruris risk. Tight jock straps trap moisture, socks are irrelevant, and brushes are unrelated.
Which instruction to the nursing assistant is best for maintaining the client's safety and security?
- A. Let the client take your arm while walking.
- B. Take the client's arm while walking.
- C. You'll see the client in front of you and to your side.
- D. Have the client walk independently by your side.
Correct Answer: A
Rationale: Allowing the client to hold the assistant's arm provides stability and safety.
The nurse is caring for a male client diagnosed with folliculitis barbae. Which information should the nurse teach to prevent a reoccurrence?
- A. Tell the client to not shave the face.
- B. Instruct the client to rub on astringent aftershave lotion.
- C. Recommend the client apply hot packs for 20 minutes before shaving.
- D. Teach the client to use an antibacterial soap on the face.
Correct Answer: D
Rationale: Antibacterial soap reduces bacterial load, preventing folliculitis barbae. Not shaving is impractical, astringents irritate, and hot packs are less effective.