Nokea
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
- A. Turn on soft music and shut the blinds.
- B. Apply warm, moist heat to the lesions.
- C. Notify the HCP for more pain medication.
- D. Encourage the client to ambulate with assistance.
Correct Answer: A
Rationale: Soft music and dim lighting provide nonpharmacologic pain relief for herpes zoster. Heat may worsen pain, more medication is premature, and ambulation is unrelated.
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Which client is at the greatest risk for the development of skin cancer?
- A. The African American male who lives in the northeast.
- B. The elderly Hispanic female who moved from Mexico as a child.
- C. The client who has a family history of basal cell carcinoma.
- D. The client with fair complexion who cannot get a tan.
Correct Answer: D
Rationale: Fair complexion and inability to tan increase UV damage risk, elevating skin cancer likelihood. Darker skin, geography, and family history are less significant.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.
When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.