Nokea
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?
- A. The client complains of pain when the medication is administered.
- B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
- C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
- D. The client is able to perform active range-of-motion exercises.
Correct Answer: C
Rationale: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
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Which client is at the greatest risk for the development of skin cancer?
- A. The African American male who lives in the northeast.
- B. The elderly Hispanic female who moved from Mexico as a child.
- C. The client who has a family history of basal cell carcinoma.
- D. The client with fair complexion who cannot get a tan.
Correct Answer: D
Rationale: Fair complexion and inability to tan increase UV damage risk, elevating skin cancer likelihood. Darker skin, geography, and family history are less significant.
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
- A. Tetanus toxoid booster
- B. Tetanus antitoxin
- C. Hyperimmune human tetanus globulin
- D. DPT booster
Correct Answer: A
Rationale: A tetanus toxoid booster is appropriate for a burn client with a tetanus shot within the past five years to ensure immunity against tetanus, common in burn wounds.
When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
When the nurse reviews the client's health history, which symptom is directly related to the development of cataracts?
- A. Gradual loss of vision
- B. Feeling of fullness within the eye
- C. Ocular pain or discomfort
- D. Flashes of light
Correct Answer: A
Rationale: Cataracts cause a gradual loss of vision due to lens opacity.
The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox?
- A. Deep vein thrombosis.
- B. Varicella pneumonia.
- C. Pericarditis.
- D. Scarring of the skin.
Correct Answer: B
Rationale: Varicella pneumonia is a serious complication in adults with chickenpox, especially older adults. DVT, pericarditis, and scarring are less common.