Nokea
The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question?
- A. Maintain heparin to achieve a therapeutic level.
- B. Initiate and monitor intravenous fluids.
- C. Keep the O₂‚ saturation higher than 93%.
- D. Administer an intravenous loop diuretic.
Correct Answer: D
Rationale: Loop diuretics are not typically indicated for fat embolism syndrome and may worsen dehydration, warranting questioning.
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The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun
- B. Try to stay out of the sun between 0300 and 0500 daily
- C. Perform a thorough skin check monthly
- D. Remember caps and long sleeves do not help prevent skin cancer
Correct Answer: C
Rationale: Monthly skin checks promote early detection of skin cancer, a key self-care practice.
Which instructions would be appropriate for the nurse to give to a client with acute conjunctivitis from Staphylococcus?
- A. Wash your hands before cleansing the eye and giving eyedrops, soak lids with warm saline, and do not share towels, make-up, or contact lenses.
- B. You can rub your eyes with a clean, soft cloth for itching.
- C. All of the above
- D. None of the above
Correct Answer: A
Rationale: Handwashing prevents cross-contamination, soaking lids softens crusts, and not sharing items reduces spread. Rubbing eyes can worsen the condition and spread infection.
Which question is most important for the operating room nurse to ask a Jewish client scheduled for a left AKA?
- A. Made special arrangements for amputated limb?
- B. Types of food preferred while hospitalized?
- C. Would like rabbi visit in recovery room?
- D. Start checking other foot daily for cuts?
Correct Answer: A
Rationale: Understanding cultural preferences regarding limb disposal is crucial.
The school nurse recognizes the signs of scabies when a child presents with:
- A. small fluid-filled blisters that sting when scratched.
- B. dry scaly patches in body creases that itch.
- C. wavy threadlike lines on the body and pruritus.
- D. cluster of papular lesions with pruritus.
Correct Answer: C
Rationale: Scabies is manifested by brown threadlike lines on the body, especially the hands, anus, and body folds. Pruritus is severe.
The nurse is providing home care instructions to a client who has recently had a skin graft. It is most important that the client remember to:
- A. Keep the graft moist at all times.
- B. Protect the graft from direct sunlight.
- C. Exercise the grafted area daily.
- D. Apply pressure dressings continuously.
Correct Answer: B
Rationale: Direct sunlight can damage the delicate new tissue of a skin graft, delaying healing and increasing scarring risk.