Nokea
When the nurse inspects the client's eyes, which clinical finding is most indicative of cataracts?
- A. Ruptured blood vessels in the eye
- B. An irregularly shaped iris
- C. A white spot behind the pupil
- D. A painless corneal lesion
Correct Answer: C
Rationale: A white spot behind the pupil indicates lens clouding, characteristic of cataracts.
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Which of the parent's statements indicates a need for further teaching?
- A. Lice are gone if I don't see any one day after treatment.
- B. I've washed all the bed linens in soap, hot water, and bleach.
- C. None of my children shares each other's combs or brushes.
- D. Once there is an outbreak, all students should be inspected.
Correct Answer: A
Rationale: Lice treatment requires follow-up to ensure all nits are eradicated.
The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?
- A. Lower torso
- B. Upper part of the body
- C. Hands and feet
- D. Perineum
Correct Answer: B
Rationale: Burns to the upper body, including the chest and face, increase the risk of respiratory complications, such as airway obstruction or inhalation injury, which are life-threatening.
The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client?
- A. Apply an ice pack to the right hand.
- B. Place the hand in cool water.
- C. Be sure to rupture any blister formation.
- D. Go immediately to the doctor’s office.
Correct Answer: B
Rationale: Cool water reduces burn progression and pain without tissue damage. Ice causes frostbite, rupturing blisters risks infection, and immediate doctor visits depend on severity.
A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?
- A. With a sterile, gloved hand
- B. With a sterile applicator
- C. With sterile 4x4's
- D. By aerosol spray
Correct Answer: C
Rationale: Sulfamylon is applied using sterile 4x4 gauze pads to ensure even coverage and maintain sterility while minimizing pain.
The nurse in the long-term care facility must delegate a nursing task to an unlicensed assistive personnel. Which nursing task would be most appropriate to delegate?
- A. Comb the nits out of the client’s hair.
- B. Massage the reddened area on the hip.
- C. Scrape the burrows to remove the scabies mite.
- D. Apply antifungal lotion to the groin area.
Correct Answer: A
Rationale: Combing nits is a non-invasive task within UAP scope. Massaging, scraping, and applying medication require nursing judgment.