Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
- A. Stock the rooms with the equipment needed.
- B. Weigh the clients and position the clients for the examination.
- C. Discuss problems the client has experienced since the previous visit.
- D. Take the biopsy specimens to the laboratory.
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, outside UAP scope. Stocking, weighing/positioning, and transporting specimens are appropriate.
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The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing?
- A. Cellulitis.
- B. Lyme disease.
- C. Impetigo.
- D. Deep vein thrombosis.
Correct Answer: A
Rationale: Redness, edema, heat, and streaks post-puncture suggest cellulitis, a bacterial infection. Lyme disease has a bullseye rash, impetigo is superficial, and DVT lacks skin changes.
The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?
- A. WBC at 9900/microL
- B. Serosanguineous drainage
- C. Temperature 103°F (39.4°C)
- D. Urine output 100 mL past 4 hours
Correct Answer: C
Rationale: An elevated temperature could be a sign of an infection. Normal WBC is 4500 to 11,100 microL, so 9900 is WNL. Clean wounds have serosanguineous drainage. Decreased urine output can indicate dehydration or renal failure, not infection.
The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
- A. Remove any mafenide that has been applied.
- B. Immediately notify the health care provider.
- C. Double-check the concentration of mafenide.
- D. Inform the client that this is a normal response.
Correct Answer: D
Rationale: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
- A. The client's face for skin lesions
- B. The client of the last dose of anticoagulant
- C. The client's right eye for drainage
- D. The client's left eye for signs of strain
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.