Nokea
The nurse suspects that a patient is experiencing a recurrent herpes simplex virus infection. Which assessment finding is most characteristic of this condition?
- A. Fever
- B. Anorexia
- C. Areas of redness
- D. Fluid-filled vesicles
Correct Answer: D
Rationale: Fluid-filled vesicles are the hallmark of recurrent herpes simplex, appearing at the site of previous infection.
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Which intervention should the nurse discuss with the client diagnosed with tinea pedis reporting intense itching?
- A. Wash feet with soap and water and dry thoroughly at least twice a day.
- B. Take the prescribed itraconazole for 1 week a month for 3 months.
- C. Use over-the-counter (OTC) antifungal powders such as miconazole.
- D. Wear clean cotton socks and change frequently to keep feet dry.
Correct Answer: A
Rationale: Washing and drying feet twice daily prevents fungal growth. Itraconazole is for tinea unguium, OTC powders are adjunctive, and socks help but washing is the primary intervention.
The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be:
- A. "Unfortunately"
- B. an autograft skin is a temporary graft and a second surgery will be needed to close the wound.?"
- C. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.?"
- D. "Yes
Correct Answer: C
Rationale: The autograft is the only permanent method of grafting and it uses the patient's own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft.
The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer
- B. Refer the client to a prosthesis specialist for prosthesis
- C. Instruct the client how to apply sunscreen to the area
- D. Demonstrate care of the surgical site
Correct Answer: D
Rationale: Post-surgical site care prevents infection and promotes healing, a key discharge instruction.
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
- A. Increase intravenous fluids by 100 mL/hr.
- B. Administer furosemide (Lasix) 40 mg IV push.
- C. Continue to monitor urine output hourly.
- D. Draw blood for serum electrolytes STAT.
Correct Answer: B
Rationale: Furosemide is inappropriate as it would worsen fluid loss in a burn client needing increased fluids.
The nurse working with children knows which burn is the most common type of burn in the pediatric population?
- A. Contact
- B. Flame
- C. Scald
- D. Thermal
Correct Answer: C
Rationale: Scald burns, caused by hot liquids or steam, are the most common in children due to their curiosity and lack of coordination (e.g., pulling hot water off stoves). 'Thermal' is a broad category, but scalds are specifically frequent.