Nokea
The nurse is preparing to perform a dressing change on a client with deep partial-thickness and full-thickness burns. Which of the following actions would be inappropriate when caring for this client?
- A. Administer an oral cyclooxygenase-2 (COX-2) inhibitor 30 minutes before the dressing change
- B. Provide a clear explanation to the client about the procedure and how it will be performed
- C. Changing the client's dressing carefully and handling burned areas gently
- D. Let the client watch their favorite television show while dressing change is being performed
Correct Answer: D
Rationale: Watching TV may distract the client but is inappropriate during a painful procedure like a dressing change, as it does not address pain or procedural needs.
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The nurse is caring for a client who sustained an electrical burn. Which priority action should the nurse take?
- A. Obtain an electrocardiogram (ECG)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Perform wound care
- D. Initiate supplemental oxygen
Correct Answer: A
Rationale: Electrical burns can cause cardiac dysrhythmias, so obtaining an ECG is the priority to assess heart rhythm.
The nurse plans to take which priority action?
- A. Assess the client's respiratory status
- B. Prepare an infusion of lactated ringers
- C. Insert an indwelling urinary catheter
- D. Obtain an accurate weight
Correct Answer: A
Rationale: Respiratory status is the priority due to the risk of airway compromise from burns to the torso and back.
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
The nurse receives a client who has just returned from a circular skin punch biopsy to confirm a skin cancer diagnosis. The nurse should prioritize observing the site for:
- A. Dehiscence
- B. Infection
- C. Bleeding
- D. Swelling
Correct Answer: C
Rationale: Bleeding is the priority concern post-punch biopsy due to the risk of hemorrhage from the procedure site.
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.