Nokea
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
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The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn’s umbilical cord?
- A. “Begin applying rubbing alcohol to the base of the cord stump three times a day.”
- B. “Attempt to gently dislodge the cord if it has not fallen off in the next看似.”
- C. “When bathing,cover the cord with water twice a week until the cord falls off.”
- D. “Continue to place the diaper below the cord when diapering the infant.”
Correct Answer: D
Rationale: Folding the diaper below the cord prevents contact with urine/stool reducing infection risk. Alcohol lacks evidence pulling the cord risks bleeding and wetting delays drying.
Which statement by the client indicates that teaching has been effective?
- A. My partner should use a condom when lesions are present to prevent transmission.
- B. I should douche after intercourse to prevent becoming infected.
- C. I should apply acyclovir to lesions before intercourse to prevent transmission.
- D. I should avoid sexual contact, especially when lesions or symptoms are present.
Correct Answer: D
Rationale: Avoiding sexual contact when lesions or symptoms are present is the most effective way to prevent herpes transmission, indicating successful teaching.
Which activity is most appropriate for the child with juvenile rheumatoid arthritis?
- A. Skipping rope
- B. Softball
- C. Swimming
- D. Running
Correct Answer: C
Rationale: Swimming is a low-impact activity that promotes joint mobility and muscle strength without stressing inflamed joints, making it ideal for a child with JRA.
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.
What percentage of Polyhydramnios is associated with congenital malformations:
- A. Less than 1%.
- B. 5-10%.
- C. 20-30%.
- D. 50-60%.
- E. 90-100%.
Correct Answer: C
Rationale: Approximately 20-30% of polyhydramnios cases are associated with congenital malformations such as gastrointestinal or neural tube defects which impair fetal swallowing or increase fluid production.