Nokea
Which nursing instruction is most appropriate before the client leaves the emergency department?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.
You may also like to solve these questions
When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
The nurse writes the client problem of 'acute pain and itching secondary to bacterial skin lesions.' Which interventions should be included in the care plan? Select all that apply.
- A. Keep humidity at less than 20%.
- B. Maintain a cool environment.
- C. Use a mild soap for sensitive skin.
- D. Keep lesions covered at all times.
- E. Apply skin lotion after bathing.
Correct Answer: B,C,E
Rationale: Cool environment, mild soap, and lotion reduce itching and pain in bacterial lesions. Low humidity worsens dryness, and constant coverage may trap moisture, promoting infection.
The female teacher comes to the school nurse’s office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?
- A. Instruct the teacher to go to her HCP today.
- B. Tell the teacher to wash her hands with soap and water.
- C. Encourage the teacher to rub vitamin E oil on the lesions.
- D. Explain that the rash will go away in a few days.
Correct Answer: A
Rationale: Impetigo requires HCP evaluation for antibiotics. Handwashing is preventive, vitamin E is ineffective, and spontaneous resolution is unlikely.
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
- A. Complete the Braden Scale.
- B. Monitor the client on a Glasgow Coma Scale.
- C. Assess for Babinski’s sign.
- D. Initiate a Brudzinski flow sheet.
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
The nurse is caring for a person who has severe poison ivy. Soaks with Burrow's solution are ordered. What is the primary reason for using Burrow's solution soaks?
- A. To disinfect the wound
- B. To prevent pain from the lesions
- C. To stop the pruritus associated with the condition
- D. To help dry the oozing lesions
Correct Answer: C
Rationale: Burrow’s solution soaks relieve pruritus (itching) in poison ivy by soothing the skin and reducing inflammation.