Nokea
What is the scientific rationale for placing lift pads under an immobile client?
- A. The pads will absorb any urinary incontinence and contain stool.
- B. The pads will prevent the client from being diaphoretic.
- C. The pads will keep the staff from workplace injuries such as a pulled muscle.
- D. The pads will help prevent friction shearing when repositioning the client.
Correct Answer: D
Rationale: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.
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The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse?
- A. The client has bilaterally weak radial pulses.
- B. The client is able to move the left fingers.
- C. The client has a CRT less than three (3) seconds.
- D. The client is unable to remove the wedding ring.
Correct Answer: D
Rationale: Inability to remove a ring in cellulitis suggests severe edema, risking compartment syndrome, requiring immediate intervention. Weak pulses, finger movement, and normal CRT are less urgent.
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
- A. Leave the draining lesion open to the air so it dries.
- B. Use strict hand washing to prevent cross-contamination.
- C. Cover the mattress and pillows with plastic covers.
- D. Apply ice to the affected area 20 minutes twice daily.
- E. Wash all linens, towels, and clothing after each use.
- F. Remove all throw rugs to prevent tripping or falls.
Correct Answer: B,C,E
Rationale: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
Which comment made to the nurse strongly suggests that the client with glaucoma needs more teaching?
- A. I must wash my hands before instilling the dress.
- B. This drug decreases the formation of fluid in my eye.
- C. I'll need to take this until my eye pressure is normal.
- D. The cap on the container should be replaced after use.
Correct Answer: C
Rationale: Glaucoma requires lifelong treatment, not just until pressure normalizes.
The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply.
- A. I apply the cream only to the opened areas of the burned area.
- B. Silver sulfadiazine will prevent an infection of the burned area.
- C. I never should apply a dressing after applying silver sulfadiazine.
- D. I use a tongue blade to remove the old ointment before reapplying.
- E. The cream is dark colored and cannot be removed with water.
Correct Answer: A,B
Rationale: Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus an infection; this statement indicates client understanding of the instructions. Dressings can be applied but are not necessary; this statement does not indicate client understanding. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding.
The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this client?
- A. Penicillin
- B. Acyclovir
- C. Tetracycline
- D. Benadryl
Correct Answer: B
Rationale: Acyclovir is the antiviral medication used to treat herpes zoster (shingles), reducing viral replication and symptom duration.