Nokea
The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation? Select all that apply.
- A. Burning sensation is felt in the affected arm.
- B. Pain reduced from 5 to 2 on a 0 to 10 scale.
- C. Irrigation runoff solution pH measures 7.0.
- D. Absence of pain in the arm with the acid burn.
- E. Affected arm skin surface pH measures 4.8.
Correct Answer: A,B,E
Rationale: The presence of a burning sensation may indicate that some acid remains on the skin and additional irrigation is needed. The presence of pain, even though reduced, could indicate that not all of the acid has been removed from the skin. A pH of 4.8 is acidic and indicates there is still acid residue that needs to be removed. A pH of 7 indicates a nonacidic status, which would be a positive finding. The absence of pain would indicate that all acid was removed before it could damage the skin.
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- A. Infection
- B. Hyperthermia
- C. Depression
- D. Malnutrition
Correct Answer: A
Rationale: Open exposure increases infection risk due to exposed tissue.
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- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
The nurse is caring for a client with complaints of a rash and itching on the face for one (1) week. Which intervention should the nurse implement first?
- A. Check for the presence of hirsutism on the face.
- B. Use the Wood’s light to visualize the rash under the black light.
- C. Determine what OTC medications the client has used on the rash.
- D. Ask the client to describe when the rash first appeared.
Correct Answer: D
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The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
- A. The ear feels less warm to the touch.
- B. Ear drainage is thin and watery.
- C. Ear discomfort is relieved.
Correct Answer: C
Rationale: Relief of ear discomfort indicates the infection is responding to treatment.