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Glasgow Coma Scale of 3✔✔✔Expect nonresponsive to commands
Angina Manifestations✔✔✔Chest discomfort radiated, pain <15mins, relieved
with rest
Diabetes Mellitus Client✔✔✔Plan to see diaphoretic client first
, Page 2 of 292
Testicular Self-Examination✔✔✔Instruct to examine after a warm shower
197.) Collagenase (Santyl) is prescribed for a client with a severe burn to the hand.
The nurse provides instructions to the client regarding the use of the medication.
Which statement by the client indicates an accurate understanding of the use of this
medication?
1. "I will apply the ointment once a day and leave it open to the air."
2. "I will apply the ointment twice a day and leave it open to the air."
3. "I will apply the ointment once a day and cover it with a sterile dressing."
4. "I will apply the ointment at bedtime and in the morning and cover it with a
sterile dressing."✔✔✔ANSWER-3. "I will apply the ointment once a day and
cover it with a sterile dressing."
Rationale:
Collagenase is used to promote debridement of dermal lesions and severe burns. It
is usually applied once daily and covered with a sterile dressing.
198.) Coal tar has been prescribed for a client with a diagnosis of psoriasis, and the
nurse provides instructions to the client about the medication. Which statement by
the client indicates a need for further instructions?
1. "The medication can cause phototoxicity."
2. "The medication has an unpleasant odor."
3. "The medication can stain the skin and hair."
, Page 3 of 292
4. "The medication can cause systemic effects."✔✔✔ANSWER-4. "The
medication can cause systemic effects."
Rationale:
Coal tar is used to treat psoriasis and other chronic disorders of the skin. It
suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an
unpleasant odor, can frequently stain the skin and hair, and can cause
phototoxicity. Systemic toxicity does not occur.
**The name of the medication will assist in eliminating options 2 and 3**
199.) A nurse is applying a topical glucocorticoid to a client with eczema. The
nurse monitors for systemic absorption of the medication if the medication is being
applied to which of the following body areas?
1. Back
2. Axilla
3. Soles of the feet
4. Palms of the hands✔✔✔ANSWER-2. Axilla
Rationale:
Topical glucocorticoids can be absorbed into the systemic circulation. Absorption
is higher from regions where the skin is especially permeable (scalp, axillae, face,
eyelids, neck, perineum, genitalia), and lower from regions where penetrability is
poor (back, palms, soles).
, Page 4 of 292
**Eliminate options 3 and 4 because these body areas are similar in terms of skin
characteristics**
200.) A client is seen in the clinic for complaints of skin itchiness that has been
persistent over the past several weeks. Following data collection, it has been
determined that the client has scabies. Lindane is prescribed, and the nurse is asked
to provide instructions to the client regarding the use of the medication. The nurse
tells the client to:
1. Apply a thick layer of cream to the entire body.
2. Apply the cream as prescribed for 2 days in a row.
3. Apply to the entire body and scalp, excluding the face.
4. Leave the cream on for 8 to 12 hours and then remove by
washing.✔✔✔ANSWER-4. Leave the cream on for 8 to 12 hours and then remove
by washing.
Rationale:
Lindane is applied in a thin layer to the entire body below the head. No more than
30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours
later. Usually, only one application is required.
201.) A nurse is preparing to administer eardrops to an infant. The nurse plans to:
1. Pull up and back on the ear and direct the solution onto the eardrum.
2. Pull down and back on the ear and direct the solution onto the eardrum.
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