Nokea
The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client?
- A. Encourage the client to get the chickenpox immunization.
- B. Do not engage in oral sex if you have a cold sore on the mouth.
- C. Wear nonsterile gloves when cleaning the genital area.
- D. Do not share any type of towel or washcloth with another person.
Correct Answer: B
Rationale: Avoiding oral sex with a cold sore (HSV-1) prevents HSV-2 transmission to genitals. Chickenpox vaccine, gloves, and towels are unrelated.
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The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing?
- A. Cellulitis.
- B. Lyme disease.
- C. Impetigo.
- D. Deep vein thrombosis.
Correct Answer: A
Rationale: Redness, edema, heat, and streaks post-puncture suggest cellulitis, a bacterial infection. Lyme disease has a bullseye rash, impetigo is superficial, and DVT lacks skin changes.
The nurse compares the characteristics of open-angle glaucoma with those of angle-closure glaucoma. Which of the following statements describe ways they are similar? Select all that apply.
- A. The visual field examination demonstrates a loss of vision.
- B. Clients are initially treated with medications.
- C. Blurred vision is a common manifestation.
- D. Attacks are self-limited but are more harmful with each episode.
- E. Surgery is often required.
Correct Answer: A,B,E
Rationale: Both types cause vision loss, are initially treated with medications, and may require surgery.
Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
When describing the examination procedure to the client, which statement by the nurse is most accurate?
- A. You'll read words that are the size of newsprint.
- B. You'll read letters from a distance of 20 feet to mears.
- C. You'll look at a color picture and identify an image.
- D. You'll look at a screen and tell me when an object appears.
Correct Answer: B
Rationale: The Snellen chart involves reading letters from 20 feet to assess visual acuity.