Nokea
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
You may also like to solve these questions
The nurse receives a client who has just returned from a circular skin punch biopsy to confirm a skin cancer diagnosis. The nurse should prioritize observing the site for:
- A. Dehiscence
- B. Infection
- C. Bleeding
- D. Swelling
Correct Answer: C
Rationale: Bleeding is the priority concern post-punch biopsy due to the risk of hemorrhage from the procedure site.
The ABCDEs of melanoma identification include which of the following? Select all that apply.
- A. Asymmetry: one half does not match the other half
- B. Birthmark: cafe au lait spot that does not fade
- C. Color: pigmentation is not uniform
- D. Diameter: greater than 6 mm
- E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Correct Answer: A, C, D, E
Rationale: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
The nurse has received a prescription for a high-potency topical corticosteroid lotion. The nurse should instruct the client to avoid applying the lotion to the client's
- A. feet
- B. face
- C. outer thigh
- D. abdomen
Correct Answer: B
Rationale: High-potency corticosteroids should not be applied to the face due to the risk of skin thinning and other side effects in this sensitive area.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 3 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the clinical data, the nurse's immediate concern is the client's
- A. risk for infection
- B. thermoregulation
- C. airway patency
- D. fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit is the immediate concern due to significant fluid loss from extensive burns, risking hypovolemic shock.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 6 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse assesses the urine output and determines whether the client is meeting the treatment goal when it reaches
- A. 0.10 mL/kg/hr
- B. 0.25 mL/kg/hr
- C. 0.4 mL/kg/hr
- D. 0.5 mL/kg/hr
Correct Answer: D
Rationale: A urine output of 0.5 mL/kg/hr indicates adequate renal perfusion and effective fluid resuscitation in burn patients.