Nokea
The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?
- A. Padding the client's sacrum and heels
- B. Obtaining an alternating air pressure mattress
- C. Using a lifting device when turning the client
- D. Keeping the head of bed lower than 30 degrees
Correct Answer: D
Rationale: Keeping the HOB higher than 30 degrees increases the shearing forces to the shoulders, sacrum, and heels. Padding and air mattresses reduce tissue pressure but not shearing forces. Using a lift sheet helps reduce friction but not shearing forces.
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Which nursing instruction is most appropriate to convey to the client?
- A. Use hypoallergenic or glycerin soap for bathing.
- B. Apply lotion to the affected skin every other day.
- C. Take showers rather than tub baths.
- D. Rub the skin dry after bathing.
Correct Answer: A
Rationale: Hypoallergenic soap minimizes irritation in dry skin.
The nurse correctly hands the physician which solution?
- A. Povidone-iodine (Betadine)
- B. Gentian violet
- C. Will have to remove my prosthesis for cleaning.
- D. Fluorescein
Correct Answer: D
Rationale: Fluorescein is used to stain the cornea to detect foreign bodies or injuries.
The public health nurse is caring for a client diagnosed with leprosy (Hansen’s disease). Which intervention should the nurse implement?
- A. Explain the need for admission to the hospital.
- B. Administer dapsone, a sulfone, for one (1) month only.
- C. Instruct to use skin moisturizing lotion to control the symptoms.
- D. Discuss the ways leprosy is transmitted to other individuals.
Correct Answer: D
Rationale: Discussing transmission (e.g., prolonged contact) educates the client, reducing stigma and risk. Hospitalization is rarely needed, dapsone is long-term, and lotion is symptomatic.
The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply.
- A. Place the client in contact isolation.
- B. Administer a corticosteroid IVP.
- C. Assess the client’s pain on a 1-to-10 scale.
- D. Request that the client not have any visitors.
- E. Ensure that only nurses who have had chickenpox care for this client.
Correct Answer: A,C,E
Rationale: Contact isolation, pain assessment, and assigning immune nurses prevent transmission and manage disseminated zoster. Corticosteroids are contraindicated, and visitor bans are excessive.
Which health teaching information is most appropriate for a client with a herpes simplex virus type 1 infection?
- A. Apply petroleum jelly to the lesions to prevent spreading the virus to adjacent areas.
- B. Use good personal hygiene to prevent spreading the virus to other body parts.
- C. Avoid using soap and water on open lesions.
- D. Remove the scabs daily by soaking with hot compresses.
Correct Answer: B
Rationale: Good hygiene prevents viral spread to other areas.