Nokea
The nurse is caring for a client who is having silver nitrate dressings. Which lab values should the nurse monitor?
- A. Blood urea nitrogen (BUN)
- B. Blood gases
- C. Complete blood count (CBC)
- D. Serum electrolytes
Correct Answer: D
Rationale: Silver nitrate can cause electrolyte imbalances, particularly hyponatremia and hypokalemia, requiring monitoring of serum electrolytes.
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Which health teaching instruction given by the nurse is most important for a client with conjunctivitis?
- A. Eat a well-balanced, nutritious diet with plenty of fluids.
- B. Always wear dark sunglasses when in bright light.
- C. Do not share towels or washcloths with family members.
- D. Avoid all aspirin-containing products.
Correct Answer: C
Rationale: Preventing the spread of conjunctivitis involves avoiding shared items like towels.
Which measure is best for the nurse to recommend?
- A. Soak affected body parts in a warm solution that is approximately 100°F (37.8°C).
- B. Massage the affected areas to restore circulation.
- C. Apply a heating pad on the highest setting to the affected body parts.
- D. Flood the affected skin surface with hot water at a temperature of approximately 140°F (60°C).
Correct Answer: A
Rationale: Warm soaking at 100°F promotes rewarming without causing burns.
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.
Which client signs and symptoms indicate contact dermatitis to the nurse?
- A. Erythema and oozing vesicles.
- B. Pustules and nodule formation.
- C. Varicosities and edema.
- D. Telangiectasia and flushing.
Correct Answer: A
Rationale: Erythema and oozing vesicles are hallmark signs of contact dermatitis. Pustules, varicosities, and telangiectasia suggest other conditions.