Nokea
A client with an ileal conduit has a rash around the stoma. The nurse should:
- A. Apply a antifungal cream.
- B. Clean with soap and water.
- C. Use a larger appliance.
- D. Cover with gauze.
Correct Answer: B
Rationale: Cleaning with soap and water removes irritants, promoting rash healing.
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The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?
- A. Inserts the needle, bevel up at a 15-degree angle
- B. Instructs the client that the test will be read in 48-72 hours
- C. Selects a site 3 to 4 finger widths below the antecubital space
- D. Administers the test using a 20-gauge needle, 2 inches long
Correct Answer: D
Rationale: A PPD test requires a 26- or 27-gauge needle, 1/2 inch long, for intradermal administration.
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.
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.
The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply.
- A. Fatigue.
- B. Unexplained weight loss with adequate nutritional intake.
- C. Rectal bleeding.
- D. Bowel changes.
- E. Positive fecal occult blood testing.
Correct Answer: A,B,C,D,E
Rationale: Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer, and blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic. CN: Health promotion and maintenance; CL: Create