Nokea
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.
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Which client is at the greatest risk for the development of skin cancer?
- A. The African American male who lives in the northeast.
- B. The elderly Hispanic female who moved from Mexico as a child.
- C. The client who has a family history of basal cell carcinoma.
- D. The client with fair complexion who cannot get a tan.
Correct Answer: D
Rationale: Fair complexion and inability to tan increase UV damage risk, elevating skin cancer likelihood. Darker skin, geography, and family history are less significant.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?
- A. The client complains of pain when the medication is administered.
- B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
- C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
- D. The client is able to perform active range-of-motion exercises.
Correct Answer: C
Rationale: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
The nurse is assessing the client. Which findings should the nurse associate with herpes zoster?
- A. Serous drainage and pus
- B. Nodular lesions and burning
- C. Painful vesicles and pruritus
- D. Macule lesions and petechiae
Correct Answer: C
Rationale: The nurse should associate pain and pruritus (itching) with herpes zoster. Herpes zoster follows the path of peripheral sensory nerves; symptoms come from the nerve involvement. Serous drainage and pus indicate infection of vesicles. Nodular lesions are not associated, though burning may occur. Macule lesions may occur early, but petechiae are not associated.
Which measure is best for the nurse to recommend?
- A. Soak affected body parts in a warm solution that is approximately 100°F (37.8°C).
- B. Massage the affected areas to restore circulation.
- C. Apply a heating pad on the highest setting to the affected body parts.
- D. Flood the affected skin surface with hot water at a temperature of approximately 140°F (60°C).
Correct Answer: A
Rationale: Warm soaking at 100°F promotes rewarming without causing burns.
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.