Nokea
Which questions should the nurse ask to investigate the cause of the client's rash? Select all that apply.
- A. Have you eaten foods that are different from your normal diet?
- B. Have you taken any new medications?
- C. Have you changed your laundry detergent?
- D. Have you been exposed to excessive sunlight?
- E. Have you been exercising in a gym?
- F. Have you gotten any new pets?
Correct Answer: A,B,C,D,F
Rationale: These factors are common triggers for rashes.
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Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
Postoperatively, which of the following client concerns should be the nurse's highest priority?
- A. Pain
- B. Waiting
- C. Anxiety
- D. Fatigue
Correct Answer: A
Rationale: Pain is a priority as it may indicate complications like infection or graft failure.
The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
- A. Remove any mafenide that has been applied.
- B. Immediately notify the health care provider.
- C. Double-check the concentration of mafenide.
- D. Inform the client that this is a normal response.
Correct Answer: D
Rationale: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
- A. Provide analgesia before pain becomes severe.
- B. Clean the client’s wounds, body, and hair daily.
- C. Screen visitors for respiratory infections.
- D. Encourage visitors to bring plants and flowers.
Correct Answer: B
Rationale: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.