Nokea
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
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On inspecting the client's eye, the nurse will note which symptom of conjunctivitis in addition to erythema?
- A. Dried drainage along the eyelid
- B. Lack of pupil response to light
- C. Bulging of the eye from the orbit
- D. Loss of moisture on the cornea
Correct Answer: A
Rationale: Conjunctivitis often presents with dried, crusty drainage along the eyelid.
Silver nitrate dressings are applied to burns on an adult. What should be included in the nursing care plan?
- A. Change the dressings every two hours.
- B. Keep the dressings wet.
- C. Carefully monitor fluid intake.
- D. Observe for black discoloration.
Correct Answer: B
Rationale: Silver nitrate dressings must be kept wet to maintain their antibacterial effectiveness and prevent tissue damage.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
- A. Constant perineal moisture.
- B. Ability of the clients to reposition themselves.
- C. Decreased elasticity of the skin.
- D. Impaired cardiovascular perfusion of the periphery.
Correct Answer: A
Rationale: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.
Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis?
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: C
Rationale: IgE mediates allergic reactions, elevated in contact dermatitis. IgA, IgD, and IgG are less relevant.