Nokea
The nurse observes the unlicensed assistive personnel (UAP) squeezing the 'blackheads' on an elderly client. Which action should the nurse implement first?
- A. Notify the unit manager of witnessing this activity.
- B. Instruct the assistant to stop this behavior.
- C. Demonstrate the correct way to care for the skin.
- D. Complete an incident report regarding the action.
Correct Answer: B
Rationale: Stopping the UAP prevents harm from inappropriate skin manipulation. Notification, demonstration, and reporting follow.
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The nurse is teaching a 24-year-old female with severe cystic acne who is prescribed a systemic retinoic acid drug. Which question is priority?
- A. Are you sexually active?
- B. Are you allergic to vitamin A?
- C. Is your skin dry or sensitive?
- D. Can you take the drug as scheduled?
Correct Answer: A
Rationale: A systemic retinoic acid drug is teratogenic. A sexually active female must be instructed to practice birth control while taking this class of drugs, to avoid pregnancy. Allergy, skin sensitivity, and adherence are important but not the priority.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
- A. High risk for infection.
- B. Ineffective coping.
- C. Impaired physical mobility.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Extensive burns increase infection risk due to loss of skin barrier; this is the priority. Coping, mobility, and knowledge are secondary in acute burn care.
A woman who has herpes simplex 1 (HSV1) around the mouth and nose asks the nurse if she can give the sores to her husband. What should the nurse include when answering this client?
- A. Herpes simplex 1 (HSV1) is a fever blister and is not contagious.
- B. She should not kiss her husband or anyone else because it can be transmitted to susceptible persons.
- C. Fever blisters are seen only in persons who have fevers.
- D. The virus is transmitted through coughing and sneezing.
Correct Answer: B
Rationale: HSV1 is contagious and can be transmitted through direct contact, such as kissing, especially during active outbreaks.
Which response by the nurse is best in this situation?
- A. Gravity helps to reattach the separated retina.
- B. I'm very small to be a reasonable, and I'm very
- C. I can get you a sedative if it's hard to lie still.
- D. The doctor knows what's best for you, and you should listen.
Correct Answer: A
Rationale: Bed rest uses gravity to aid retinal reattachment.
Which assessment finding is commonly noted when the intraocular pressure (IOP) of a client with angle-closure glaucoma becomes dangerously high?
- A. Spots in the visual field
- B. Severe eye pain
- C. Pinpoint pupils
- D. Bulging eyes
Correct Answer: B
Rationale: Acute angle-closure glaucoma causes severe eye pain due to rapidly elevated IOP.