Nokea
The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
You may also like to solve these questions
The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?
- A. Skin discoloration
- B. Hardened eschar
- C. Increased neutrophils
- D. Urine sulfa crystals
Correct Answer: D
Rationale: Urine sulfa crystals. When applied to extensive areas, silver sulfadiazine may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.
The nurse is providing education for a client with newly diagnosed tuberculosis. Which statement should be included in the information that is given to the client?
- A. Isolate yourself from others until you are finished taking your medication.'
- B. Follow up with your primary care provider in 3 months.'
- C. Continue to take your medications even when you are feeling fine.'
- D. Continue to get yearly tuberculin skin tests.'
Correct Answer: C
Rationale: The most important piece of information the tuberculosis client needs is to understand the importance of medication compliance, even if no longer experiencing symptoms. Clients are most infectious early in the course of therapy. The numbers of acid-fast bacilli are greatly reduced as early as 2 weeks after therapy begins.
The client recently has had a myocardial infarction. Which medications should the nurse anticipate the health-care provider recommending to prevent another heart attack?
- A. Vitamin K and a nonsteroidal anti-inflammatory drug.
- B. Vitamin E and a daily low-dose aspirin.
- C. Vitamin A and an anticoagulant.
- D. Vitamin B complex and an iron supplement.
Correct Answer: B
Rationale: Low-dose aspirin prevents platelet aggregation, reducing MI risk, per ACC/AHA guidelines. Vitamin E lacks evidence for secondary prevention; other options are irrelevant or contraindicated.
Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
Prior to administering Alteplase (TPA) to a client admitted for a cerebral vascular accident (CVA), it is critical that the nurse assess:
- A. Neuro signs
- B. Mental status
- C. Blood pressure
- D. PT/PTT
Correct Answer: D
Rationale: PT/PTT. TPA is a potent thrombolytic enzyme. Because bleeding is the most common side effect, it is most essential to evaluate clotting studies including PT, PTT, APTT, platelets, and hematocrit before beginning therapy.