1. A client with atopic dermatitis is prescribed medication for
photochemotherapy. After administering medication for photochemotherapy,
the nurse determines that the client understands the instructions based on
which client statements? Select all that apply.
A. "I must protect my skin and eyes from natural sunlight for 12 hours
after taking this medication."
B. "I will need to wear wraparound ultraviolet-protective sunglasses both
indoors and outdoors, from the moment I take the medication until nightfall
on the treatment day."
C. "I will need to wear protective-wear wraparound ultraviolet-protective
sun-glasses after dark if I am under fluorescent lighting."
D. "As long as I am inside behind a window glass I will not need to wear
my protective glasses."
E. "I will need to wear broad-spectrum sunscreen if I am outside.": A. "I
must protect my skin and eyes from natural sunlight for 12 hours after taking this
medication."
B. "I will need to wear wraparound ultraviolet-protective sunglasses both indoors
and outdoors, from the moment I take the medication until nightfall on the treatment
day." C. "I will need to wear protective-wear wraparound ultraviolet-protective
sunglasses after dark if I am under fluorescent lighting."
E. "I will need to wear broad-spectrum sunscreen if I am outside."
Explanation: Clients must avoid sun exposure even behind window glass for 12
hours after ingesting medication for photochemotherapy such as methoxsalen.
Clients must protect their skin and eyes from natural sunlight for 12 hours after
taking the tablets. During treatment, clients must wear wraparound ultraviolet-
protective sunglasses both indoors and outdoors from the moment they take the
tablets until nightfall on treatment day. After dark, the glasses must still be worn
under fluorescent lighting, but are not necessary outside or with incandescent
lamps. Clients should wear covering clothing and apply broad-spectrum sunscreens
if outdoors.
2. The nurse is caring for a wheelchair-bound client. Which piece of
equipment impedes circulation to the area it is meant to protect?
A. air-fluidized bed
B. ring or donut
C. gel flotation pad
,D. water bed: B. ring or donut
Explanation: Rings or donuts are not to be used because they restrict circulation.
An air-fluidized bed contains beads that move under an airflow to support the client,
thus reducing shearing force and friction. Gel pads redistribute with the client's
weight.
The water bed also distributes pressure over the entire surface.
3. The nurse is caring for a client with a postoperative wound evisceration.
Which action should the nurse perform first?
A. Explain to the client what is happening and provide support.
B. Cover the protruding internal organs with sterile gauze moistened with
sterile saline solution.
C. Push the protruding organs back into the abdominal cavity.
D. Ask the client to drink as much fluid as possible.: B. Cover the protruding
internal organs with sterile gauze moistened with sterile saline solution.
Explanation: The nurse should first cover the wound with moistened gauze to
prevent the organs from drying. Both the gauze and the saline solution must be
sterile to reduce the risk of infection. The nurse should provide support that will
reduce the client's anxiety, but covering the wound is the top priority. The organs
should not be pushed back into the abdomen because doing so may tear or damage
them. Evisceration requires emergency surgery; therefore, the nurse should place
the client on nothing-by-mouth status immediately.
4. While assessing a client, a nurse notes a stage I pressure ulcer on the
client's left hip. How should the nurse report this finding?
A. Document the size, extent, and location of the wound in the client's
medical record.
B. Inform the client's family of the pressure ulcer.
C. Notify a physician immediately.
D. Report the finding to a nurse-manager immediately.: A. Document the size,
extent, and location of the wound in the client's medical record.
5. When assisting with developing a plan of care for a client recovering from
a serious thermal burn, the nurse knows that the most important immediate
goal of therapy is:
A. planning for the client's rehabilitation and discharge.
B. providing emotional support to the client and family.
, NUR 101 Exam 3
C. maintaining the client's fluid, electrolyte, and acid-base balance.
D. preserving full range of motion in all affected joints.: C. maintaining the
client's fluid, electrolyte, and acid-base balance.
Explanation: The most important immediate goal of therapy for a client with a
serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid
potentially life- threatening complications, such as shock, disseminated
intravascular coagulation (DIC), respiratory failure, cardiac failure, and acute tubular
necrosis.
The other options are important aspects of care but don't take precedence over
maintaining the client's fluid, electrolyte, and acid-base balance.
6. A child was found unconscious at home and brought to the emergency
department by the fire and rescue unit. While collecting data, the nurse
observes cherry-red mucous membranes, nail beds, and skin. Which cause
is the most likely explanation for the child's condition?
A. Aspirin ingestion
B. Carbon monoxide poisoning
C. Hydrocarbon ingestion
D. Spider bite: B. Carbon monoxide poisoning
Explanation: Cherry-red skin changes are seen when a child has been exposed to
high levels of carbon monoxide. Nausea and vomiting and pale skin are symptoms
of aspirin ingestion. A hydrocarbon or petroleum ingestion usually results in
respiratory symptoms and tachycardia. Spider-bite reactions are usually localized
to the area of the bite.
7. A client transferred to a long-term care facility has a stage II pressure ulcer
on her coccyx. Who should the nurse consult about the care of this client? A.
Charge nurse
B. Physician
C. Wound care nurse
D. Risk management: C. Wound care nurse
Explanation: The wound care nurse should be consulted for a treatment plan for this
client. The charge nurse and physician 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 ulcers are a continual problem.
, 8. The nurse is gathering data from a client with an abdominal incision and
suspects there is a potential for delayed wound healing. Which observation
most likely supports this finding?
A. sutures dry and intact
B. wound edges in close approximation
C. purulent drainage on a soiled wound dressing
D. sanguineous drainage in a wound-collection drainage bag: C. purulent
drainage on a soiled wound dressing
Explanation: Purulent drainage contains white blood cells, which fight infection. The
sutures from a wound that is draining purulent secretions would pull away with
an infection. Wound edges can't approximate in an infected wound. Sanguineous
drainage indicates bleeding, not infection.
9. The nurse is collecting data from several clients at the clinic. Which client
does the nurse determine is most likely receive the Zostavax vaccine for the
prevention of shingles?
A. 24-year old client that will be traveling out of the country
B. 6-month-old infant having surgery to repair a cleft lip
C. 62-year-old client that had a mild case of shingles 4 years previouslyD.
38-year-old pregnant client that has gestational diabetes: C. 62-year-old
client that had a mild case of shingles 4 years previously
Explanation: The Centers for Disease Control and Prevention (CDC) recommends
that anyone 60 years of age or older receive the shingles vaccine, even if they have
had a previous case of shingles to prevent reoccurrence of the virus. The other
clients are not at greater risk for the development of shingles.
10. The nurse is preparing to perform wound care for a client. What action
should the nurse prioritize before changing the dressing?
A. put on gloves
B. wash hands thoroughly
C. slowly remove the soiled dressing
D. observe the dressing for the amount, type, and odor of drainage: B. wash
hands thoroughly
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