Nokea
The nurse has received a prescription for a high-potency topical corticosteroid lotion. The nurse should instruct the client to avoid applying the lotion to the client's
- A. feet
- B. face
- C. outer thigh
- D. abdomen
Correct Answer: B
Rationale: High-potency corticosteroids should not be applied to the face due to the risk of skin thinning and other side effects in this sensitive area.
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The nurse receives a client who has just returned from a circular skin punch biopsy to confirm a skin cancer diagnosis. The nurse should prioritize observing the site for:
- A. Dehiscence
- B. Infection
- C. Bleeding
- D. Swelling
Correct Answer: C
Rationale: Bleeding is the priority concern post-punch biopsy due to the risk of hemorrhage from the procedure site.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 4 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Click to specify the interventions the nurse anticipates incorporating into the client's care plan
- A. Insertion of indwelling urinary catheter
- B. Irrigate wounds with cool saline solution
- C. Implement fluid restrictions
- D. Remove any jewelry from affected extremity
- E. Administer tetanus prophylaxis (Tdap)
Correct Answer: A, D, E
Rationale: Inserting a urinary catheter monitors fluid resuscitation, removing jewelry prevents constriction, and tetanus prophylaxis prevents infection. Cool saline is avoided as it can cause hypothermia, and fluid restrictions are inappropriate.
A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
- A. Administer dopamine as ordered
- B. Apply medical anti-shock trousers
- C. Infuse IV fluids as indicated
- D. Infuse fresh frozen plasma
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 3 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the clinical data, the nurse's immediate concern is the client's
- A. risk for infection
- B. thermoregulation
- C. airway patency
- D. fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit is the immediate concern due to significant fluid loss from extensive burns, risking hypovolemic shock.
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.