Nokea
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate potential compartment syndrome, requiring urgent intervention.
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The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?
- A. Obtain a sample of the drainage for culture and sensitivities.
- B. Determine any allergic reactions to any medications taken recently.
- C. Inquire how the poison ivy/oak plants were destroyed.
- D. Assess for any temperature elevation since the last visit to the clinic.
Correct Answer: D
Rationale: Temperature elevation could indicate a secondary infection, a common complication needing prompt assessment.
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?
- A. The patient applies corticosteroid cream to pruritic areas.
- B. The patient uses Neosporin ointment on minor cuts or abrasions.
- C. The patient adds oilated oatmeal (Aveeno) to the bath water every day.
- D. The patient takes diphenhydramine (Benadryl) at night if itching occurs.
Correct Answer: B
Rationale: Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient.
What problem is most appropriate for the nurse to identify for a client with a closed fracture of the right arm?
- A. Risk for ineffective coping related to inability to perform ADLs
- B. Risk for compartment syndrome related to injured muscle tissue
- C. Risk for infection related to exposed bone and tissue
- D. Risk for complications related to compromised neurovascular status
Correct Answer: D
Rationale: Compromised neurovascular status poses significant risks requiring vigilant monitoring.
Which medication or treatment should the nurse discuss with a teenage client diagnosed with mild acne?
- A. Injections of Clostridium botulinum into the acne lesions.
- B. Applying vitamin E oil directly to the acne pimples to keep them moist.
- C. Taking isotretinoin by mouth daily.
- D. Washing the face and neck morning and night with benzoyl peroxide.
Correct Answer: D
Rationale: Benzoyl peroxide suppresses P. acnes and promotes peeling for mild acne. Botox is for wrinkles, vitamin E worsens oiliness, and isotretinoin is for severe acne.
The clinic nurse is assessing the skin of a white client who is diagnosed with psoriasis. Which of the following characteristic is associated with this skin disorder?
- A. Red, inflamed patches
- B. Thick, oozing sores
- C. Small, fluid-filled blisters
- D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions
Correct Answer: D
Rationale: Psoriasis is characterized by silvery-white scales over red plaques, commonly on the scalp, elbows, knees, and sacral area.