PassPoint
While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
"All family members will need to be treated." Explanation: When someone sharing a home contracts scabies, each individual in the home needs prompt treatment whether he's symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective?
"I'll eat plenty of fruits and vegetables." Explanation: For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. To acquire these nutrients, the client should eat a high-protein diet with plenty of fruits, vegetables, lean meats, poultry, and fish. To avoid impeding circulation to the area, the bandage should be secure but not tight. The client's foot should not feel cold; a cold extremity indicates impaired circulation, which inhibits wound healing.
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he has sustained burns to which percentage of his body?
27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs are each 18% of the total body surface. The head, neck, and arms are each 9% of total body surface, and the perineum is 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster?
76-year-old client taking immunosuppressant medication Explanation: Herpes zoster (shingles) is an acute inflammation caused by infection with the herpes virus varicella-zoster (chickenpox virus). It is most common in adults age 65 years and older. Others at risk include clients with decreased immunity (transplants, HIV/AIDS, immunosuppressant medications, etc.), chronic lung or kidney disease, or clients who had chickenpox at a younger age.
A child has been brought to the ED with a bite to the arm from a dog. What action by the nurse will assist in the prevention of infection?
Clean and irrigate the wounds. Explanation: Not every dog bite requires antibiotic therapy, but cleaning the wound is necessary for all injuries involving a break in the skin. Rabies vaccine is used if the dog is suspected of having rabies. The infection rate for dog bites has been reported to be as high as 50%.
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?
Contact isolation Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, used to prevent transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.
The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply.
Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others. Explanation: It is important to keep cuts and scrapes clean and covered to prevent bacterial invasion by staphylococcus aureus and other bacteria. Hands should be washed with soap and water after activities and contact with potential sources of infection. Do not share personal objects with others such as towels, razors, etc. The use of prophylactic antibiotic ointment may cause problems with antibiotic resistance and should be discouraged.
Which intervention has the highest priority when providing skin care to a bedridden client?
Keeping the skin clean and dry without using harsh soaps Explanation: Keeping the skin clean is always the highest priority. The other measures are also important but only after the skin is cleaned.
When talking with the parents of a child with erythema infectiosum (fifth disease), the nurse should include which statement?
Pregnant women are at risk for fetal death if infected with fifth disease. Explanation: There's a 3% to 5% risk of fetal death from hydrops fetalis if a pregnant woman is exposed during the first trimester. The cutaneous eruption of fifth disease can reappear for up to 4 months. A child with fifth disease is contagious during the first stage, not after the rash, when symptoms of headache, body aches, fever, and chills are present. The child should be isolated from pregnant women, immunocompromised clients, and clients with chronic anemia for up to 2 weeks.
The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?
dry, cracked lips, strawberry tongue Explanation: Oral changes associated with Kawasaki disease include a reddened pharynx; red, dry fissured lips; and strawberry tongue. Koplik spots are consistent with measles. Tonsillar exudate is consistent with pharyngitis caused by group A beta-hemolytic streptococci. Vesicular lesions are associated with coxsackievirus.
While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. What does this finding suggest?
harlequin color change Explanation: Harlequin color change is a benign disorder related to the immaturity of the hypothalamic centers that control the tone of peripheral blood vessels. A newborn who has been lying on its side may appear reddened on the dependent side. The color fades on position change. Contact dermatitis is not short-lived. Changes in environmental conditions can cause diffuse bilateral mottling of the skin. Tet spells are associated with tetralogy of Fallot and cause cyanotic changes.
A nurse is caring for a client with a pressure injury on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize?
lean meats and low-fat milk Explanation: Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein but also fat, which should be limited to 30% or less of caloric intake. Whole-grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.
The incidence of hospital-acquired pressure injuries on the medical-surgical unit has increased. Who should the nurse inform about this concern?
risk manager Explanation: The risk manager will evaluate the problem to help resolve it. The provider will treat the problem after it has occurred, but they are not responsible for preventing the problem from recurring. The other nursing staff will be in a position to provide preventive care, but not to analyze the trend. It is not necessary to notify the case manager.
The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing?
wash hands thoroughly Explanation: The first thing the nurse must do is wash hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of the dressing change procedure that come after hand washing.
A client transferred to a long-term care facility has a stage II pressure injury on their coccyx. Who should the nurse consult about the care of this client?
wound care nurse Explanation: The wound care nurse should be consulted for a treatment plan for this client. The charge nurse and provider should be informed, but the wound care nurse will be the resource person to institute a wound care protocol. Risk management should be informed if pressure injuies are a continual problem.
