Nokea
The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this client?
- A. Penicillin
- B. Acyclovir
- C. Tetracycline
- D. Benadryl
Correct Answer: B
Rationale: Acyclovir is the antiviral medication used to treat herpes zoster (shingles), reducing viral replication and symptom duration.
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The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.
When the nurse prepares the client for the myringotomy, which statement best explains the purpose of the procedure?
- A. A myringotomy prevents permanent hearing loss.
- B. A myringotomy provides a pathway for drainage.
- C. A myringotomy aids in administering medications.
- D. A myringotomy maintains motion of the ear bones.
Correct Answer: B
Rationale: A myringotomy creates an opening for fluid drainage, relieving pressure.
The client is being admitted to the ED after a house fire. Place the client's problems in the order of priority in which they should be addressed by the nurse.
- A. Has 48% partial- and full-thickness burn injury
- B. Laceration on the face that has stopped bleeding
- C. Inhalation injury from smoke
- D. History of hypertension
Correct Answer: C,A,B,D
Rationale: Inhalation injury from smoke is the priority problem that should be addressed first to ensure that the client has a patent airway. The 48% partial- and full-thickness burn injury should be addressed next due to fluid loss and pain. The laceration on the face that has stopped bleeding should be addressed next, possibly requiring suturing. History of hypertension can be addressed last, as fluid shifts from the burn are likely to lower BP.
The nurse is planning teaching for the client who is using miconazole cream topically for tinea pedis. Which instruction should the nurse include?
- A. Cover the treated area with an occlusive dressing.
- B. Avoid washing the area prior to applying the cream.
- C. Massage miconazole into the affected area of the foot.
- D. Once symptoms resolve, discontinue using miconazole.
Correct Answer: C
Rationale: Tinea pedis is athlete's foot. Miconazole (Lotrimin AF) should be massaged into the affected area. Occlusive dressings should be avoided to prevent systemic absorption. The area should be washed and dried before application. Miconazole should be continued for the full course of therapy.