Nokea
Which is the initial intervention for relief of the pruritus of dermatitis venenata?
- A. Apply baking soda to lesions.
- B. Wash area with copious amounts of water.
- C. Apply cool compresses continuously.
- D. Expose area to air.
Correct Answer: B
Rationale: In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately after contact with the offending allergen. Applying baking soda is not effective. Cool compresses and air exposure are not the initial intervention.
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Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed in which way?
- A. stage 1.
- B. stage 2.
- C. stage 3.
- D. stage 4.
Correct Answer: B
Rationale: Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. Stage 1 involves intact skin with non-blanchable redness. A stage 3 pressure injury involves full-thickness tissue loss and sometimes subcutaneous fat is visible. At stage 4, there is a full thickness tissue loss with exposed bone, tendon, cartilage or muscle.
A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?
- A. shock.
- B. respiratory arrest.
- C. hemorrhage.
- D. infection.
Correct Answer: D
Rationale: Infection is the most common complication and cause of death after the first 72 hours. Shock, due to hypovolemia is most common during the emergent phase of the burn injury. Respiratory arrest and hemorrhage are not common causes of death.
A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction will be helpful in managing the pruritus?
- A. Use cool, wet dressings and baths to promote vasoconstriction.
- B. Trim the fingernails short to prevent skin damage from scratching.
- C. Expose the areas to the sun to promote drying and healing of the lesions.
- D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation.
Correct Answer: A
Rationale: Wet dressings and using Burow's solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. Exposing the areas to the sun will not manage pruritus. Wearing cotton gloves may prevent environmental irritation, but will not help the existing pruritis.
The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?
- A. Transport victim to hospital.
- B. Cover victim with clean cloth or sheet.
- C. Stop, drop, and roll.
- D. Remove all nonadherent clothing and jewelry.
Correct Answer: C
Rationale: The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital.