Nokea
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
- A. Sterile gloves
- B. Patch test instruments
- C. Cotton-tipped applicators
- D. Local anesthetic, syringe, and intradermal needle
Correct Answer: C
Rationale: Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection is not needed because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens.
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The clinic nurse is assessing the skin of a white client who is diagnosed with psoriasis. Which of the following characteristic is associated with this skin disorder?
- A. Red, inflamed patches
- B. Thick, oozing sores
- C. Small, fluid-filled blisters
- D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions
Correct Answer: D
Rationale: Psoriasis is characterized by silvery-white scales over red plaques, commonly on the scalp, elbows, knees, and sacral area.
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
- A. Macules
- B. Papules
- C. Vesicles
- D. Pustules
Correct Answer: A
Rationale: A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?
- A. Carbon monoxide poisoning always occurs when soot is visible.
- B. Inhalation injury above the glottis may cause significant edema that obstructs the airway.
- C. The patient will have a copious amount of mucus that will need to be suctioned.
- D. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.
Correct Answer: B
Rationale: In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
The nurse is preparing to administer influenza vaccines to a mass drive-through clinic. Which statement by a client would indicate further questioning prior to giving the client the influenza vaccine?
- A. I am allergic to horse hair.'
- B. I try to get my vaccine every year.'
- C. I am not allergic to anything except eggs.'
- D. My husband had a severe allergic reaction after he received his influenza vaccine.'
Correct Answer: C
Rationale: Influenza vaccines are recommended for persons at high risk for serious sequelae of influenza. The nurse should be aware that a client with a sensitivity to eggs should not receive the vaccine. Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs.
Based on the data of a 66-year-old male with a sacral ulcer and low prealbumin, which action should the nurse take?
- A. Perform a neuromuscular assessment.
- B. Request a dietary consult.
- C. Initiate Contact Precautions.
- D. Assess the client's vital signs.
Correct Answer: B
Rationale: The low prealbumin count indicates poor nutritional status, putting the client at risk for inadequate wound healing, necessitating a dietary consult.