Page 1229 - Saunders Comprehensive Review For NCLEX-RN

staff members cannot be assigned to care for a client with herpes zoster?
Select all that apply.
1. The nurse who never had roseola
2. The nurse who never had mumps
3. The nurse who never had chickenpox
4. The nurse who never had German measles
5. The nurse who never received the varicella-zoster vaccine

Answers

423. Answer: 4

Rationale: In the event of a snakebite, the first priority is to move the victim to a
safe area away from the snake and encourage the victim to rest to decrease venom
circulation. Next, jewelry and constricting clothing are removed before swelling
occurs. Immobilizing the extremity and maintaining the extremity below heart level
would be done next; these actions limit the spread of the venom. The victim is kept
warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to
the victim because these products may speed the absorption of the venom. The
victim should be transported to an emergency facility as soon as possible.
Test-Taking Strategy: Note the strategic words, first priority. Eliminate options 1
and 3 first because they are comparable or alike and relate to positioning of the
affected extremity. For the remaining options, think about them and visualize each.
Moving the victim to a safe area is the priority to prevent further injury from the
snake.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management: Prioritizing
Health Problem: Adult Health: Integumentary: Bites and Stings
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 136, 138.

424. Answer: 3

Rationale: When an individual comes in contact with a poison ivy plant, the sap
from the plant forms an invisible film on the human skin. The client should be
instructed to cleanse the area by showering immediately and to lather the skin
several times and rinse each time in running water. Removing the poison ivy sap
will decrease the likelihood of irritation. Calamine lotion may be one product
recommended for use if dermatitis develops. The client does not need to be seen in
the emergency department at this time.
Test-Taking Strategy: Focus on the subject, contact with poison ivy. Recalling that
dermatitis can develop from contact with an allergen and that contact with poison
ivy results in an invisible film will assist in directing you to the correct option.
Level of Cognitive Ability: Applying

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