Nokea
When the nurse assesses the client's operative eye after surgery, which finding is most expected?
- A. The pupil appears cloudy and gray.
- B. The pupil is a fixed size and shape.
- C. The entire iris lacks color.
- D. A section of the iris appears black.
Correct Answer: B
Rationale: An iridectomy creates a fixed pupil opening to relieve pressure.
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There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?
- A. Use only hand-washing foam when caring for clients with scabies.
- B. Wear gloves when providing hands-on care for a client with scabies.
- C. Wash all linen and clothes in cold water and dry them outside in the sun.
- D. Instruct clients to use plastic eating utensils for meals.
Correct Answer: B
Rationale: Gloves prevent scabies transmission during direct contact. Hand-washing foam is insufficient, hot water washing is needed, and plastic utensils are irrelevant.
Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)?
- A. A male African American soldier.
- B. A female Caucasian hairdresser.
- C. A male Asian food server.
- D. A female Hispanic schoolteacher.
Correct Answer: A
Rationale: Pseudofolliculitis barbae is common in African American males due to curly hair causing ingrown hairs post-shaving. Other groups are less affected.
Which nursing action is most helpful for reducing or eliminating feedback from the client's hearing aid?
- A. Repositioning the hearing aid within the ear
- B. Cleaning the hearing aid with a soft cloth
- C. Replacing the battery in the hearing aid
- D. Turning down the volume in the hearing aid
Correct Answer: A
Rationale: Repositioning corrects improper fit, reducing feedback noise.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
- A. Impaired cognition.
- B. Altered nutrition.
- C. Self-care deficit.
- D. Altered coping.
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
On the basis of the nurse's understanding of the etiology of pressure ulcers, the nurse should plan for which intervention to promote the client's skin integrity?
- A. Apply a skin-toughening agent to susceptible areas.
- B. Massage skin areas that remain persistently red.
- C. Keep the head of the bed elevated 30 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning relieves pressure, preventing ulcer progression.