Nokea
The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?
- A. WBC at 9900/microL
- B. Serosanguineous drainage
- C. Temperature 103°F (39.4°C)
- D. Urine output 100 mL past 4 hours
Correct Answer: C
Rationale: An elevated temperature could be a sign of an infection. Normal WBC is 4500 to 11,100 microL, so 9900 is WNL. Clean wounds have serosanguineous drainage. Decreased urine output can indicate dehydration or renal failure, not infection.
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The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a long-term goal, preventing complications from viral lesions. Refraining from scratching, itch relief, and infection prevention are interventions.
Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
- A. The client's face for skin lesions
- B. The client of the last dose of anticoagulant
- C. The client's right eye for drainage
- D. The client's left eye for signs of strain
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.