Nokea
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in hot water daily.
- B. Inspect your feet daily for cuts or sores.
- C. Wear tight shoes to support your arches.
- D. Cut your toenails with rounded edges.
Correct Answer: B
Rationale: daily foot inspection is essential to detect early signs of injury or infection in diabetes
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A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?
- A. This is a normal finding indicating no problem in the sinuses.
- B. Inflammation is present in the sinuses.
- C. The cavity likely contains fluid or pus.
- D. The client has a sinus infection.
Correct Answer: C
Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.
While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
- A. Stop the medication from infusing
- B. Flush the IV catheter with normal saline
- C. Apply a tourniquet and call the doctor
- D. Continue the IV and assess the site for edema
Correct Answer: A
Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.