Nokea
A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has:
- A. Voided completely.
- B. Signed the consent.
- C. Vital signs recorded.
- D. Name band on wrist.
Correct Answer: B
Rationale: Verifying that the client has signed the consent form is the priority before surgery to ensure informed consent and legal compliance. Voiding, recording vital signs, and checking the name band are also important but secondary to consent verification.
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A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
The nurse is teaching a client about a newly prescribed doxycycline. Which of the following statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication with milk or cheese.
- B. If I develop foul-smelling diarrhea I should contact my doctor.
- C. I need to wear sunscreen outdoors while taking this medication.
- D. I can stop this medication when I feel better.
- E. I should take this medication on an empty stomach.
Correct Answer: A,D
Rationale: Doxycycline should not be taken with dairy products like milk or cheese (Choice A) because calcium can bind to the medication and reduce its absorption. Choice D is incorrect because antibiotics like doxycycline should be taken for the full prescribed course to prevent resistance and ensure complete treatment. Choice B is correct; foul-smelling diarrhea could indicate a serious infection like Clostridium difficile. Choice C is correct; doxycycline causes photosensitivity, requiring sunscreen. Choice E is correct; taking doxycycline on an empty stomach improves absorption.
What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat
- A. multiple sclerosis.
- B. human immunodeficiency virus (HIV).
- C. Parkinson's disease.
- D. Guillain-Barré syndrome.
Correct Answer: B
Rationale: Tenofovir and emtricitabine (Truvada) are antiretroviral medications used to treat and prevent HIV. They are not used for multiple sclerosis (A), Parkinson’s disease (C), or Guillain-Barré syndrome (D).
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.