Nokea
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or 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 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 client is being admitted to the ED after a house fire. Place the client's problems in the order of priority in which they should be addressed by the nurse.
- A. Has 48% partial- and full-thickness burn injury
- B. Laceration on the face that has stopped bleeding
- C. Inhalation injury from smoke
- D. History of hypertension
Correct Answer: C,A,B,D
Rationale: Inhalation injury from smoke is the priority problem that should be addressed first to ensure that the client has a patent airway. The 48% partial- and full-thickness burn injury should be addressed next due to fluid loss and pain. The laceration on the face that has stopped bleeding should be addressed next, possibly requiring suturing. History of hypertension can be addressed last, as fluid shifts from the burn are likely to lower BP.
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
- A. Turn on soft music and shut the blinds.
- B. Apply warm, moist heat to the lesions.
- C. Notify the HCP for more pain medication.
- D. Encourage the client to ambulate with assistance.
Correct Answer: A
Rationale: Soft music and dim lighting provide nonpharmacologic pain relief for herpes zoster. Heat may worsen pain, more medication is premature, and ambulation is unrelated.
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.