Nokea
Which activity should the client who underwent a stapedectomy avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
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The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
- A. A 22-gauge intravenous line with normal saline infusing.
- B. Wounds covered with moist sterile dressings.
- C. No intravenous pain medication.
- D. Ensure adequate peripheral circulation to both feet.
Correct Answer: D
Rationale: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
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.
The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
- A. The lesion is asymmetrical and has irregular borders.
- B. The lesion has a waxy appearance with pearlike borders.
- C. The lesion has a thickened and scaly appearance.
- D. The lesion appeared as a thickened area after an injury.
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.
The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.
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.