Nokea
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
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If a client with a middle ear infection reports the following symptoms, the blood pressure and the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.
The nurse is working with clients in an aesthetic surgery center. Which intervention should the nurse implement for a client undergoing a chemical peel?
- A. Teach the client to expect extreme swelling after the procedure.
- B. Apply the chemical mixture directly to skin after the face is cleansed.
- C. Administer general anesthesia to the client prior to the procedure.
- D. Explain that there will be no pain or discomfort during the procedure.
Correct Answer: B
Rationale: Applying the chemical post-cleansing ensures efficacy and safety. Extreme swelling is not typical, general anesthesia is unnecessary, and mild discomfort is expected.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.