Nokea
A client with a new ileostomy is concerned about returning to work. Which advice should the nurse provide to support the client's transition?
- A. Wear loose clothing to conceal the pouch.
- B. Avoid all physical activity for 6 months.
- C. Change the pouch daily regardless of output.
- D. Limit fluid intake to reduce output.
Correct Answer: A
Rationale: Wearing loose clothing helps conceal the ileostomy pouch, boosting the client's confidence at work. Avoiding activity is unnecessary, daily pouch changes are not required unless needed, and limiting fluids risks dehydration. CN: Psychosocial adaptation; CL: Synthesize
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The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply.
- A. To ensure efficient and accurate communication.
- B. To prevent medication errors.
- C. To ensure client safety.
- D. To make it easier for clients to understand the medication orders.
- E. To make data entry into a computerized health record easier.
Correct Answer: A,B,C
Rationale: Eliminating dangerous abbreviations ensures clear communication, prevents medication errors, and enhances client safety by reducing misinterpretations. Client understanding and data entry ease are secondary benefits.
Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line?
- A. Use a clean technique for all dressing changes.
- B. Tape all connections of the system.
- C. Encourage bed rest.
- D. Cover the insertion site with a moisture-proof dressing.
Correct Answer: B,D
Rationale: To prevent complications with TPN via a central line, taping all connections (B) prevents dislodgement, and a moisture-proof dressing (D) reduces infection risk. Clean technique (A) is insufficient; sterile technique is required. Bed rest (C) is not necessary and may increase complications like thrombosis. CN: Pharmacological and parenteral therapies; CL: Create
Which medication is prescribed to prevent uric acid stones?
- A. Hydrochlorothiazide.
- B. Allopurinol.
- C. Potassium citrate.
- D. Acetaminophen.
Correct Answer: B
Rationale: Allopurinol reduces uric acid levels, preventing stone formation.
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client?
- A. You must shampoo your hair tonight to remove all oil and dirt.
- B. You may drink fluids until midnight, but after that drink nothing until the scan is completed.
- C. You will have some hair shaved to attach the small electrode to your scalp.
- D. You will need to hold your head very still during the examination.
Correct Answer: D
Rationale: Holding the head still during a CT scan is essential to obtain clear images. Shampooing, fasting, or shaving hair for electrodes are not required for a non-contrast head CT.
The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.