Nokea
The nurse is providing home care instructions to a client who has recently had a skin graft. It is most important that the client remember to:
- A. Keep the graft moist at all times.
- B. Protect the graft from direct sunlight.
- C. Exercise the grafted area daily.
- D. Apply pressure dressings continuously.
Correct Answer: B
Rationale: Direct sunlight can damage the delicate new tissue of a skin graft, delaying healing and increasing scarring risk.
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A child has lice. The parent wants to know what to do with the child's stuffed animals. Which response by the nurse is most appropriate?
- A. Seal in a plastic bag in the garage for 2 weeks.
- B. Spray with an anti-lice fumigating product.
- C. Throw them away; they cannot be cleaned.
- D. Wash in hottest water possible and line dry.
Correct Answer: A
Rationale: Lice cannot survive long without a human host. Sealing stuffed animals in a plastic bag for 2 weeks kills lice by depriving them of a food source, making it an effective and practical solution.
Which question is most important for the operating room nurse to ask a Jewish client scheduled for a left AKA?
- A. Made special arrangements for amputated limb?
- B. Types of food preferred while hospitalized?
- C. Would like rabbi visit in recovery room?
- D. Start checking other foot daily for cuts?
Correct Answer: A
Rationale: Understanding cultural preferences regarding limb disposal is crucial.
What is the first priority action for a nurse caring for a client who has suffered a snakebite?
- A. Immobilize the extremity
- B. Move the victim to a safe area away from the snake
- C. Remove jewelry and constricting clothing
- D. Keep the victim warm and calm
Correct Answer: B
Rationale: The first priority is to move the victim to a safe area to prevent further injury from the snake.
Which intervention should the nurse implement to prevent infection in a client with burn injuries?
- A. Ask all family members and visitors to perform hand hygiene before touching the client.
- B. Carefully monitor burn wounds when providing each dressing change.
- C. Clean equipment with alcohol between uses with each client on the unit.
- D. Allow family members to only bring the client plants from the hospital's gift shop.
Correct Answer: A
Rationale: Hand hygiene by all prevents infection transmission.
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first?
- A. Beige freckles on the backs of both hands
- B. Irregular blue mole with white specks on the lower leg
- C. Large cluster of pustules in the right axilla
- D. Thick, reddened papules covered by white scales
Correct Answer: B
Rationale: This mole fits criteria for being cancerous or precancerous: variation of color and irregular border.