Nokea
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.
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The nurse is caring for a client with a new diagnosis of glaucoma. Which medication class should the nurse expect to administer?
- A. Beta-blockers
- B. Antibiotics
- C. Corticosteroids
- D. Antihistamines
Correct Answer: A
Rationale: Beta-blockers, such as timolol, reduce intraocular pressure in glaucoma by decreasing aqueous humor production, the primary treatment goal.
A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions targeting which of the following problems?
- A. Drug and alcohol abuse.
- B. Risk for injury.
- C. Severe pain.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: Severe pain is a primary concern in acute pancreatitis, requiring targeted interventions like analgesics.
An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
- A. Excitability
- B. Bradycardia
- C. Hypertension
- D. Poor skin turgor
- E. Flat peripheral veins
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?
- A. 164/90 mm Hg
- B. 156/89 mm Hg
- C. 140/94 mm Hg
- D. 128/84 mm Hg
Correct Answer: D
Rationale: Normal blood pressure readings are less than 120/80 mm Hg. A blood pressure reading between 120/80 mm Hg and 139/89 mm Hg is considered to be a prehypertensive state. From the readings provided in the options, the correct option identifies the most successful outcome, although the reading indicates a prehypertensive state.
A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
- A. Increased infection risk.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.