A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)

Apply ice to the larger blisters.

Administer ibuprofen for pain.

Maintain skin integrity over the blisters.

Run cool water over the affected area.

Allow the affected area to remain open to air.

Answer and Explanation

Correct Answer : D,E

Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.

A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.

B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.

C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.

Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.

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Correct Answer is C

Explanation

The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.

Option B - Throat culture should be obtained before the initial dose of antibiotics.

Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

A. "You will be moderately sedated during the procedure." B. "You will lie on your right side for the procedure." C. "You may drink full liquids until 6 hours before the procedure." D. "You should warm the liquid bowel preparation before drinking it."

Correct Answer is A

Explanation

The correct answer is Choice a. "You will be moderately sedated during the procedure."

Choice A rationale: Colonoscopy is a common procedure used for both diagnostic and therapeutic purposes in gastroenterology. Moderate sedation, also known as conscious sedation, is typically administered to patients undergoing colonoscopy to ensure their comfort and cooperation during the procedure. This level of sedation allows the patient to maintain their protective reflexes and respond to verbal commands, while also reducing anxiety and discomfort. The sedative agents commonly used for colonoscopy include benzodiazepines such as midazolam and analgesics such as fentanyl. The nurse should emphasize the use of moderate sedation to the patient, reassuring them that they will be in a relaxed state throughout the procedure without compromising their safety.

Choice B rationale: The statement suggesting that the patient will lie on their right side for the procedure is incorrect. During a colonoscopy, patients are typically positioned on their left side with their knees drawn up towards their chest. This left lateral decubitus position facilitates the advancement of the colonoscope through the colon and provides better visualization for the healthcare provider performing the procedure. Placing the patient on the right side would not provide optimal positioning and may hinder the progress of the colonoscopy.

Choice C rationale: The information provided in statement c. is incorrect regarding the dietary restrictions before a colonoscopy. Prior to the procedure, patients are instructed to follow a clear liquid diet for 24 to 48 hours, depending on the healthcare provider's instructions. Clear liquids include water, clear broth, tea, coffee without milk or cream, strained fruit juices (such as apple or white grape juice), and sports drinks. Solid foods, as well as liquids that are not transparent, should be avoided during this preparatory period to ensure adequate bowel cleansing and visualization during the colonoscopy.

Choice D rationale: The recommendation to warm the liquid bowel preparation before consumption, as stated in option d., is incorrect. Bowel preparations typically consist of polyethylene glycol-based solutions, which are intended to be consumed at room temperature or chilled. Warming the solution could alter its composition and taste, potentially causing discomfort or nausea in the patient. It is essential for patients to follow the specific instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation to ensure effective bowel cleansing before the colonoscopy.

Choice E rationale: Repeated for emphasis, the advice to warm the liquid bowel preparation before consumption is incorrect and redundant. Patients should adhere strictly to the instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation. Warming the solution is not recommended and could compromise the effectiveness of the preparation, leading to suboptimal bowel cleansing and potentially impacting the accuracy of the colonoscopy results.

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A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?

A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?

A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?