Nokea
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include?
- A. Avoid using alcohol-based hand sanitizer
- B. Use disposable dishes and utensils for all meals
- C. Wear a surgical mask when you are out in public
- D. Keep the wound covered with a dry bandage
Correct Answer: D
Rationale: Keeping the wound covered with a dry bandage prevents the spread of MRSA and protects the wound from further contamination.
You may also like to solve these questions
The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply.
- A. Increased secretion of epinephrine
- B. Increased secretion of antidiuretic hormone (ADH)
- C. Increased secretion of aldosterone
- D. Decreased levels of glucose
- E. Increased secretion of norepinephrine
Correct Answer: A, B, C, E
Rationale: Major burns cause a stress response, increasing epinephrine, ADH, aldosterone, and norepinephrine to compensate for fluid loss and maintain homeostasis. Glucose levels increase, not decrease, due to stress-induced hyperglycemia.
The nurse is caring for a client with a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
- A. Alginate
- B. Dry gauze
- C. Hydrocolloid
- D. Transparent
Correct Answer: C
Rationale: Hydrocolloid dressings are appropriate for shallow, partial-thickness pressure ulcers as they maintain a moist environment to promote healing.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 4 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Click to specify the interventions the nurse anticipates incorporating into the client's care plan
- A. Insertion of indwelling urinary catheter
- B. Irrigate wounds with cool saline solution
- C. Implement fluid restrictions
- D. Remove any jewelry from affected extremity
- E. Administer tetanus prophylaxis (Tdap)
Correct Answer: A, D, E
Rationale: Inserting a urinary catheter monitors fluid resuscitation, removing jewelry prevents constriction, and tetanus prophylaxis prevents infection. Cool saline is avoided as it can cause hypothermia, and fluid restrictions are inappropriate.
The nurse is discussing how to provide foot care to clients to a group of unlicensed assistive personnel (UAPs). The nurse should reinforce that Select all that apply.
- A. mild soap and tepid water should be used
- B. the feet should be soaked in hot water and oil
- C. The feet should be dried thoroughly, as well as in between the toes
- D. an alcohol rub may be used if the feet appear dry
- E. scaling and discoloration of the feet should be reported to the nurse
- F. The toenails should be cut at the lateral corners when trimming the nails
Correct Answer: A, C, E
Rationale: Mild soap and tepid water, thorough drying, and reporting abnormalities are correct. Hot water, alcohol rubs, and cutting toenails at corners can cause injury or infection.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 6 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse assesses the urine output and determines whether the client is meeting the treatment goal when it reaches
- A. 0.10 mL/kg/hr
- B. 0.25 mL/kg/hr
- C. 0.4 mL/kg/hr
- D. 0.5 mL/kg/hr
Correct Answer: D
Rationale: A urine output of 0.5 mL/kg/hr indicates adequate renal perfusion and effective fluid resuscitation in burn patients.