Nokea
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
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The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.
The nurse correctly teaches the client that psoriasis is an inflammatory dermatosis that results from which skin condition?
- A. A superficial skin infection
- B. The effects of dermal abrasion
- C. A proliferation of epidermal cells
- D. An infection of the hair follicles
Correct Answer: C
Rationale: Psoriasis involves rapid epidermal cell turnover.
The nurse is assessing the client using desoximetasone topical cream for an abdominal rash. Which finding should indicate to the nurse that the client is experiencing a known side effect from the medication?
- A. Skin discoloration
- B. Skin thickening
- C. Decreased striae
- D. Increased skin hair
Correct Answer: A
Rationale: The presence of skin discoloration such as purpura and hyperpigmentation should indicate to the nurse that the client has a side effect from using desoximetasone (Topicort). Thinning skin, not thickening, is a side effect. The presence of striae, not a decrease, is a side effect. Folliculitis, not increased skin hair, is a side effect.
A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question?
- A. Showering daily with antiseptic soap should be sufficient.
- B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary.
- C. Psoriasis is not contagious, so no special precautions are necessary.
- D. Psoriasis is transmitted primarily by direct contact with the skin.
Correct Answer: C
Rationale: Psoriasis is a non-contagious autoimmune condition, so no precautions are needed to prevent transmission to family members.
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.