Nokea
The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.
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The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation? Select all that apply.
- A. Burning sensation is felt in the affected arm.
- B. Pain reduced from 5 to 2 on a 0 to 10 scale.
- C. Irrigation runoff solution pH measures 7.0.
- D. Absence of pain in the arm with the acid burn.
- E. Affected arm skin surface pH measures 4.8.
Correct Answer: A,B,E
Rationale: The presence of a burning sensation may indicate that some acid remains on the skin and additional irrigation is needed. The presence of pain, even though reduced, could indicate that not all of the acid has been removed from the skin. A pH of 4.8 is acidic and indicates there is still acid residue that needs to be removed. A pH of 7 indicates a nonacidic status, which would be a positive finding. The absence of pain would indicate that all acid was removed before it could damage the skin.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.
What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
It is most appropriate for the nurse to monitor a client for which potential problem?
- A. Infection
- B. Hyperthermia
- C. Depression
- D. Malnutrition
Correct Answer: A
Rationale: Open exposure increases infection risk due to exposed tissue.
The nurse is caring for a client with complaints of a rash and itching on the face for one (1) week. Which intervention should the nurse implement first?
- A. Check for the presence of hirsutism on the face.
- B. Use the Wood’s light to visualize the rash under the black light.
- C. Determine what OTC medications the client has used on the rash.
- D. Ask the client to describe when the rash first appeared.
Correct Answer: D
Rationale: Determining rash onset provides critical history for diagnosis. Hirsutism, Wood’s light, and OTC medication history are secondary.