Nokea
The experienced nurse is observing the new nurse administer medications. Which actions by the new nurse require the experienced nurse to intervene? Select all that apply.
- A. Applies tretinoin to an open wound on the face of the client with acne
- B. Withholds isotretinoin until the client's pregnancy status is known
- C. Withholds fluorouracil because the client's papules of actinic keratosis are worse
- D. Waits two hours after the client bathes and uses lotion to apply tacrolimus
- E. Tells the client taking acitretin for psoriasis to prevent pregnancy for a year
Correct Answer: A,C,E
Rationale: Tretinoin (Retin-A) should not be applied to open wounds; the experienced nurse should intervene. Actinic keratosis treatment using fluorouracil (Carac) causes the affected area to become worse before getting better; the medication should not be withheld. When taking acitretin (Soriatane), the client should not become pregnant for three years following treatment. Withholding isotretinoin until pregnancy status is known is appropriate. Waiting two hours to apply tacrolimus after lotion is correct.
You may also like to solve these questions
Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
If a client with a middle ear infection reports the following symptoms, the blood pressure and the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
What is the best nursing advice for individuals who have frequent outbreaks of tinea pedis (athlete's foot)?
- A. Never go barefoot when outdoors.
- B. Cut the nails straight across.
- C. Wear different shoes each day.
- D. Avoid wearing white cotton socks.
Correct Answer: C
Rationale: Alternating shoes allows drying, reducing fungal growth.