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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.
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The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
- A. 36
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.
The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.
If the physician wants to check the client's intraocular pressure (IOP), which instrument should the nurse have available?
- A. Ophthalmoscope
- B. Tonometer
- C. Retinoscope
- D. Speculum
Correct Answer: B
Rationale: A tonometer measures intraocular pressure, essential for glaucoma assessment.
Which instruction to the nursing assistant is best for maintaining the client's safety and security?
- A. Let the client take your arm while walking.
- B. Take the client's arm while walking.
- C. You'll see the client in front of you and to your side.
- D. Have the client walk independently by your side.
Correct Answer: A
Rationale: Allowing the client to hold the assistant's arm provides stability and safety.
When the nurse assesses the client's operative eye after surgery, which finding is most expected?
- A. The pupil appears cloudy and gray.
- B. The pupil is a fixed size and shape.
- C. The entire iris lacks color.
- D. A section of the iris appears black.
Correct Answer: B
Rationale: An iridectomy creates a fixed pupil opening to relieve pressure.