Nokea
A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?
- A. Mild edema
- B. Minimal bleeding
- C. Rose color
- D. Dark red color
Correct Answer: D
Rationale: A dark red stoma indicates inadequate blood supply, an abnormal finding requiring intervention. Mild edema, minimal bleeding, and rose color are normal postoperative findings.
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The nurse is teaching the client newly started on propranolol for acute situational anxiety disorder. In addition to treating the client's anxiety, the nurse should inform the client that propranolol's use is effective in treating which associated problem?
- A. Bradycardia
- B. Hand tremors
- C. Muscle spasms
- D. Hypertensive crisis
Correct Answer: B
Rationale: Propranolol (Inderal), a beta blocker, has been shown to be effective in ameliorating the somatic symptoms of anxiety such as hand tremor.
In teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?
- A. Use a soft toothbrush
- B. Use dental floss daily
- C. Hold pressure on any scrapes for 1-2 minutes
- D. Use a triple-edged razor
Correct Answer: A
Rationale: A soft toothbrush minimizes gum bleeding in leukemia clients with low platelets. Dental floss and razors increase bleeding risk, and pressure should be held for 5-10 minutes.
The Native American client is being assessed for emotional distress following a family crisis. In anticipating pharmacological treatment, the nurse understands that the Native American client would most likely do what?
- A. Use herbal remedies and other plant therapies with healing properties
- B. Attempt to manage emotional problems on his or her own to avoid shame
- C. Rely heavily on family for support during treatment for emotional distress
- D. Want a well-established relationship with an HCP before accepting treatment
Correct Answer: A
Rationale: Native American cultures often use herbal or plant remedies with healing properties.
A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct Answer: C
Rationale: Furosemide, a diuretic, commonly causes potassium loss, leading to hypokalemia, which can potentiate digitalis toxicity, requiring close monitoring.
The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?
- A. Allow the child to chew on a cooled teething ring.
- B. Massage the child's gums gently.
- C. Administer acetaminophen.
- D. Administer aspirin.
Correct Answer: D
Rationale: Aspirin should not be recommended as a pain medication for children due to the increased risk of Reye's syndrome.