Nokea
The nurse is evaluating a client three days post-operative for signs and symptoms of infection. Which of the following is not a sign of infection from a surgical wound?
- A. Pus and clear drainage from the site
- B. Some redness along the edges of the site
- C. Increasing warmth from the wound
- D. Red streaks from the site
Correct Answer: B
Rationale: Some redness along the edges of a surgical wound is a normal part of the healing process, whereas pus, increasing warmth, and red streaks indicate infection.
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The nurse is planning a community health course about the prevention of Lyme disease. Which of the following information should the nurse include?
- A. You should try limiting your outdoor activities between 10 a.m. and 4 p.m.
- B. Wear sunglasses that wrap around and block UVA and UVB rays.
- C. Wear long-sleeved clothing when in heavily wooded areas.
- D. Apply sunscreen with at least an SPF of 30.
Correct Answer: C
Rationale: Wearing long-sleeved clothing in wooded areas reduces skin exposure to ticks, which transmit Lyme disease.
The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.
- A. Lymphadenopathy
- B. Vaginal discharge
- C. Paresthesia
- D. Dysmenorrhea
- E. Malaise
Correct Answer: A,C,E
Rationale: Lymphadenopathy, paresthesia, and malaise are prodromal symptoms of genital herpes outbreaks, indicating viral reactivation.
The nurse is interviewing a client who wants to anonymously test themselves for the human immunodeficiency (HIV) virus. The nurse should recommend which type of testing?
- A. HIV home self testing
- B. Rapid testing at the primary healthcare providers (PHCPs) office
- C. Inpatient antibody testing
- D. Community health fair rapid testing
Correct Answer: A
Rationale: HIV home self-testing allows for anonymity and convenience, aligning with the client's preference for privacy.
The following scenario applies to the next 1 items
The nurse in the urgent care clinic is caring for a 22-year-old male client.
Item 1 of 1
Nurses' Notes
Orders
Procedure Note
1400: Client reports swelling, erythema, and painful lesion to the left upper extremity. The client reports that he noticed a pimple-like lesion three days ago that grew in size and became painful over the course of three days. The client has a medical history of diabetes mellitus (type one) and has noticed higher-than-normal blood glucose levels. The client reports that pain has increased to a level where he cannot go to the gym daily. On assessment, the client has a large, reddened pustule in the left upper extremity. Pain rated 7/10 on the Numerical Rating Scale. Vital signs: T 98.7° F (37.1° C) P 88 RR 16 BP 138/84 Pulse oximetry reading 99% on room air.
1519: Bedside I&D performed by physician. Applied 4x4 gauze sponge to the wound and wrapped with rolled sterile gauze. Culture and sensitivity were obtained and sent to the lab.
1610: Discharged client home. Discharge teaching provided. Vital signs: T 98.7° F (37.1° C) P 82 RR 17 BP 133/81 Pulse oximetry reading 98% on room air.
The nurse provides the client with discharge teaching on wound care and the prescribed antibiotic.
The nurse provides the client with discharge teaching on wound care and the prescribed antibiotic. For each of the statements made by the client, click to specify whether the statement indicates an understanding or no understanding of the discharge teaching provided.
- A. I should increase my overall fluid intake to 3 liters daily.
- B. I should wear a broad-spectrum sunscreen while outdoors.
- C. This infection may raise my glucose level.
- D. I may have to change antibiotics depending on the lab test results.
- E. I should keep the wound open to air while sleeping.
- F. I will place soiled bandages in a plastic bag and seal it closed before placing it in the regular trash.
- G. I should wash the infected area before washing the uninfected areas with a washcloth.
Correct Answer: A: Understanding, B: No Understanding, C: Understanding, D: Understanding, E: No Understanding, F: Understanding, G: Understanding
Rationale: A: Adequate fluid intake supports healing and antibiotic efficacy. B: Sunscreen is unrelated to wound care. C: Infections can elevate glucose levels, especially in diabetics. D: Antibiotic adjustments may be needed based on culture results. E: Wounds should be kept covered to prevent contamination. F: Proper disposal of bandages prevents infection spread. G: Washing the infected area first prevents spreading bacteria.
The emergency department (ED) nurse is triaging a client who is highly suspected of having inhalation anthrax. The nurse should plan to
- A. place a surgical mask on the client.
- B. place the client in a room with negative airflow with an anteroom.
- C. obtain a urine sample from the client.
- D. report the situation to the hospital administration.
Correct Answer: B
Rationale: Inhalation anthrax requires airborne precautions due to its high infectivity, necessitating a negative airflow room to prevent spread.