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What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
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The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.
The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview?
- A. Do you live in an area where animals roam the street?'
- B. Have you been working in your garden lately?'
- C. Have you been deer hunting in the last week?'
- D. Do you use sunscreen when you are outside?'
Correct Answer: C
Rationale: A bullseye rash and systemic symptoms suggest Lyme disease, linked to tick exposure during activities like deer hunting. Animal roaming, gardening, and sunscreen are less relevant.
The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.
The nurse is teaching a class on the prevention of cancer. Which information should be included regarding how to reduce the risk of skin cancer?
- A. Avoid prolonged exposure to the sun.
- B. Shower immediately after being outdoors.
- C. Avoid strong perfumes, hand creams, and body lotions.
- D. After being in the woods or in tall grass, check for ticks.
Correct Answer: A
Rationale: Avoiding prolonged sun exposure reduces ultraviolet radiation damage, a primary risk factor for skin cancer.
The nurse is caring for the client with a split-thickness skin graft taken from the thigh to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?
- A. Obtain serial wound cultures of the donor site.
- B. Eliminate plants and flowers in the client's room.
- C. Use clean technique for all wound care procedures.
- D. Administer a continual low dosage of an IV antibiotic.
Correct Answer: B
Rationale: Pseudomonas has been found in plants and flowers, which may be a source of wound infection. Wound cultures are used to confirm an infection but do not prevent one. Sterile technique, not clean technique, would eliminate additional sources of infection. Continual low-dosage antibiotic infusions would not be effective due to increased metabolism in burn clients.