Nokea
Which signs and symptoms indicate that the nursing assistant has had an allergic reaction to the latex gloves? Select all that apply.
- A. Raised areas and blisters on the hands
- B. Itchy, red, watery eyes
- C. Nausea and vomiting
- D. Hives
- E. Chest tightness
Correct Answer: A,B,D,E
Rationale: These symptoms indicate a latex allergy, ranging from local to systemic reactions.
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The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- A. Appearance of red, elevated plaques with silvery white scales.
- B. A burning, prickling row of vesicles located along the torso.
- C. Raised, flesh-colored papules with a rough surface area.
- D. An overgrowth of tissue with an excessive amount of collagen.
Correct Answer: A
Rationale: Red plaques with silvery scales are characteristic of psoriasis. Vesicles suggest herpes zoster, papules suggest warts, and collagen overgrowth suggests keloids.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
- A. Replace fluids and electrolytes.
- B. Prevent contractures of extremities.
- C. Monitor urine output hourly.
- D. Prepare to assist with an escharotomy.
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.
Which plan best promotes a blind client's feeling of self-reliance when eating?
- A. Help the client locate food by comparing its placement to clock positions.
- B. Ask a hospital volunteer to feed the client so the client does not have to ask for help.
- C. Order foods that can be sipped from containers rather than eaten with utensils.
- D. Ask the dietary department to serve the client's food on paper plates and in cups.
Correct Answer: A
Rationale: Using clock positions empowers the client to eat independently by orienting them to food placement.
The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply.
- A. Monitor intake and output every eight (8) hours.
- B. Assess breath sounds and rate every four (4) hours.
- C. Assess vesicles, erosions, and crusts frequently.
- D. Perform the whisper test for auditory changes daily.
- E. Assess orientation to person, place, and time every shift.
Correct Answer: A,B,C,E
Rationale: Monitoring I&O, breath sounds, skin lesions, and orientation address SJS complications (fluid loss, respiratory issues, skin breakdown, neurological changes). Whisper test is irrelevant.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.