Nokea
Which nursing action is most appropriate at this time?
- A. Obtaining the client's pulse and blood pressure
- B. Monitoring the client for respiratory distress
- C. Identifying the client's next of kin
- D. Determining the extent of the burn
Correct Answer: B
Rationale: Burns to the chest and neck risk airway compromise, requiring respiratory monitoring.
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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 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.
After cataract surgery, the client tells the nurse of severe pain in the operative eye. Which nursing action is most appropriate?
- A. Report the finding to the charge nurse.
- B. Give the client a prescribed analgesic.
- C. Assess the client's pupil response with a penlight.
- D. Reposition the client on the operative side.
Correct Answer: A
Rationale: Severe pain may indicate complications, requiring immediate reporting to the charge nurse.
The nurse is preparing the client scheduled for a dermabrasion. Which information should the nurse include while teaching the client?
- A. Erythema will go away within 24 hours.
- B. Do not change the dressing until seen by the HCP.
- C. Stay out of extreme cold or heat situations.
- D. Avoid direct sunlight for three (3) days.
Correct Answer: C
Rationale: Avoiding extreme temperatures protects healing skin post-dermabrasion. Erythema persists longer, dressings may be changed, and sunlight avoidance lasts weeks.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.