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The nurse is working with clients in an aesthetic surgery center. Which intervention should the nurse implement for a client undergoing a chemical peel?
- A. Teach the client to expect extreme swelling after the procedure.
- B. Apply the chemical mixture directly to skin after the face is cleansed.
- C. Administer general anesthesia to the client prior to the procedure.
- D. Explain that there will be no pain or discomfort during the procedure.
Correct Answer: B
Rationale: Applying the chemical post-cleansing ensures efficacy and safety. Extreme swelling is not typical, general anesthesia is unnecessary, and mild discomfort is expected.
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The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
The nurse is ordered to insert an indwelling catheter in a severely burned client for which reason?
- A. To prevent contamination of burned areas
- B. To measure hourly urine output
- C. To prevent urinary tract infection
- D. To detect internal injuries quickly
Correct Answer: B
Rationale: An indwelling catheter is used to measure hourly urine output, which guides fluid resuscitation to prevent shock in severe burn clients.
Silver nitrate dressings are applied to burns on an adult. What should be included in the nursing care plan?
- A. Change the dressings every two hours.
- B. Keep the dressings wet.
- C. Carefully monitor fluid intake.
- D. Observe for black discoloration.
Correct Answer: B
Rationale: Silver nitrate dressings must be kept wet to maintain their antibacterial effectiveness and prevent tissue damage.
If a client with a middle ear infection reports the following symptoms, which one suggests that the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
If a client who has recently experienced diminished hearing takes medications from each of the following drug categories, which one is most likely to have affected the client's hearing?
- A. Nonsteroidal anti-inflammatory drug
- B. Beta-adrenergic blocker
- C. Aminoglycoside antibiotic
- D. Histamine-2 (H2) antagonist
Correct Answer: C
Rationale: Aminoglycosides are ototoxic and can cause hearing loss.