Nokea
Which of the parent's statements indicates a need for further teaching?
- A. Lice are gone if I don't see any one day after treatment.
- B. I've washed all the bed linens in soap, hot water, and bleach.
- C. None of my children shares each other's combs or brushes.
- D. Once there is an outbreak, all students should be inspected.
Correct Answer: A
Rationale: Lice treatment requires follow-up to ensure all nits are eradicated.
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The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client?
- A. Immobilization of the graft site
- B. Weight-bearing exercises to the graft site
- C. Assist client out of bed as much as tolerated
- D. Maintain right leg in a dependent position
Correct Answer: A
Rationale: The graft must be immobilized so that it can remain in place and be able to revascularize. The client cannot place weight on the graft site. Bearing weight causes trauma. A dependent position impairs circulation and may cause further tissue injury.
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.
Which information provided by the nurse will best prepare the client for the caloric test?
- A. Cold water and warm water will be instilled into each of the ears.
- B. You will wear earphones through which sounds are transmitted.
- C. The room will be darkened, and scalp electrodes will be attached to the head.
- D. Your blood will be drawn from a vein and examined microscopically.
Correct Answer: A
Rationale: The caloric test involves instilling water to assess vestibular function.
When the nurse inspects the client's eyes, which clinical finding is most indicative of cataracts?
- A. Ruptured blood vessels in the eye
- B. An irregularly shaped iris
- C. A white spot behind the pupil
- D. A painless corneal lesion
Correct Answer: C
Rationale: A white spot behind the pupil indicates lens clouding, characteristic of cataracts.