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 providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?
- A. I should eat a high-protein, high-carbohydrate diet to provide energy.'
- B. It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.'
- C. I should avoid constipation to decrease chances of bleeding.'
- D. If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.'
Correct Answer: C
Rationale: Avoiding constipation (C) prevents ammonia buildup and bleeding risks. High-protein diets (A) may worsen encephalopathy, acetaminophen (B) is hepatotoxic, and cirrhosis is irreversible (D).
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
The nurse is caring for a client with cancer experiencing chronic pain and episodes of breakthrough pain. Which prescription should the nurse request from the primary healthcare provider (PHCP) to provide effective pain control?
- A. Hydromorphone via patient-controlled analgesia (PCA)
- B. Morphine intramuscular (IM) as needed (PRN) for pain
- C. Oxycodone extended-release (ER) by mouth (PO)
- D. Ketorolac via intravenous (IV) push
Correct Answer: A
Rationale: Hydromorphone via PCA allows for both continuous and patient-controlled dosing, ideal for managing chronic cancer pain with breakthrough episodes.
The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
- A. Pour the solution over ice chips.
- B. Mix the solution with an antacid.
- C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
- D. Disguise the solution in a pureed fruit or vegetable.
Correct Answer: C
Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.
What should the nurse include in the care plan for a client with a spinal cord injury?
- A. Frequent repositioning.
- B. High-protein diet.
- C. Limited mobility exercises.
- D. Fluid restriction.
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in clients with spinal cord injuries.