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The female client calls the clinic and tells the nurse that she has a really big 'boil' in the perineal area that is causing a lot of pain. Which intervention should the nurse implement?
- A. Schedule an emergency appointment for the client.
- B. Instruct the client to apply warm, moist compresses to the area.
- C. Determine if someone can squeeze the boil.
- D. Explain that this will resolve on its own.
Correct Answer: B
Rationale: Warm, moist compresses promote drainage and pain relief in a boil (furuncle). Emergency visits may be needed later, squeezing risks infection, and spontaneous resolution is unlikely.
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The nurse in a dermatology clinic is taking the history of a client. Which questions should the nurse ask the client? Select all that apply.
- A. When did you first notice the skin problem?
- B. What cosmetics or skin products do you use?
- C. Have you experienced any loss of sensation?
- D. What is your current and previous occupation?
- E. Do you experience any itching, burning, or tingling?
Correct Answer: A,B,C,D,E
Rationale: All listed questions assess onset, triggers, symptoms, and occupational exposures, critical for dermatologic history.
Which common ailment should the nurse instruct the client who underwent a stapedectomy to immediately report to the physician?
- A. The common cold
- B. A sore throat
- C. A productive cough
- D. Conjunctivitis
Correct Answer: A
Rationale: A cold can lead to middle ear pressure changes, risking surgical complications.
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
The nurse is working with clients in an aesthetic surgery center. Which intervention should the nurse implement for a client undergoing a chemical peel?
- A. Teach the client to expect extreme swelling after the procedure.
- B. Apply the chemical mixture directly to skin after the face is cleansed.
- C. Administer general anesthesia to the client prior to the procedure.
- D. Explain that there will be no pain or discomfort during the procedure.
Correct Answer: B
Rationale: Applying the chemical post-cleansing ensures efficacy and safety. Extreme swelling is not typical, general anesthesia is unnecessary, and mild discomfort is expected.
The nurse is planning care for the client with a Stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in this client's care? Select all that apply.
- A. Obtain cultures of the wound daily.
- B. Clean vigorously to remove dead tissue.
- C. Cover with a protective dressing.
- D. Reposition at least every two hours.
- E. Elevate the right heel completely off the bed.
Correct Answer: C,D,E
Rationale: The dressing protects the underlying wound and provides a moist environment for healing. The client should be repositioned at least every 2 hours. Positioning devices are utilized to keep the load or pressure off the wound. Daily wound cultures are unnecessary, as all wounds contain bacteria. The wound should be cleansed gently to prevent further tissue trauma.