NCLEX Questions: week 2

The nurse is assisting in providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton. Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

The nurse is reinforcing sun exposure precautions to a group of older clients. Which would the nurse include in the instructions? Select all that apply.

-Apply sunscreen liberally 15 to 30 minutes before sun exposure. -Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. -It is best to avoid exposure to the sun during the day between 1000 and 1600.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

-Eat a nutritious diet with adequate protein. -Use a pressure relief pad while in a wheelchair. -Check the bottom sheet for wetness and wrinkles.

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome?

Characteristic of a thrush infection

The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse?

Check that the tubing is securely attached.

An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which sign or symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position would the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg

A client is receiving chemotherapy that carries a risk of phototoxicity as an adverse effect. Which finding indicates that the client experienced this side effect?

Erythema

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

Hyperventilation

The nurse is reinforcing instructions to the client on how to maintain optimal skin integrity during external radiation therapy. The nurse determines that there is a need for further teaching if the client states plans to do which action?

Keep at least 6 feet away from pregnant individuals, especially in the first 3 months.

The physician has prescribed a bacteriostatic agent effective against both gram-positive and gram-negative organisms for application to a burn wound. The nurse determines that which medication has been prescribed?

Mafenide acetate

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse.

A physician writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions would the nurse take before transferring the client to the burn center? Select all that apply.

-Wrap burned fingers separately to prevent sticking together. -Cover the burns with a clean, dry cloth, as directed by a burn center. -Apply cool water to the area.

A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines that infiltration has occurred. In order of priority, which actions would the nurse take? Arrange the actions in the order they would be performed. All options must be used.

1.) Stop the infusion. 2.) Remove the intravenous catheter. 3.) Apply a compress to the site. 4.) Notify the registered nurse to start a new IV on the right extremity.

The nurse caring for a client with a postoperative abdominal wound observes that the client's dressing has Montgomery ties in place. The nurse determines that this intervention will decrease the risk of which complication?

Skin irritation surrounding the wound

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F orally. The white blood cell (WBC) count is 7500 mm3. Which interpretation does the nurse make of these findings? Laboratory Results WBC count 7500/mm3 (5000-10,000/mm3)

The incision line is slightly edematous but shows no active signs of infection.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment would the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

A client calls the emergency department and tells the nurse that they have been cleaning a wooded area and that they came into direct contact with poison ivy shrubs. The client tells the nurse that they cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client?

"Take a shower immediately, and lather and rinse several times."

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

A white color to the skin, which is insensitive to touch

The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication?

Apply to cleansed, debrided wounds as prescribed.