Nokea
A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?
- A. Discourage sitz baths because they promote bacterial growth.
- B. Apply zinc oxide ointment to the rectal area after each bowel movement to protect the skin.
- C. Apply a skin-barrier dressing daily to the rectal area to form a protective barrier.
- D. Clean the rectal area with unscented soap and water after each bowel movement, rinse well, and pat dry.
Correct Answer: D
Rationale: Cleaning with unscented soap and water, rinsing, and patting dry after each bowel movement prevents skin breakdown and maintains integrity in clients with diarrhea.
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After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
- A. Dehydration.
- B. Post-dural puncture headache.
- C. Hypertension.
- D. Migraine exacerbation.
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.
The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply.
- A. Monitor temperature and report elevation.
- B. Recognize signs and symptoms of infection.
- C. Avoid crowds.
- D. Maintain integrity of skin and mucous membranes.
- E. Take a baby aspirin each day.
Correct Answer: A,B,C,D
Rationale: Leukemia increases infection risk due to impaired immune function. Monitoring temperature, recognizing infection signs, avoiding crowds, and maintaining skin/mucous membrane integrity are critical to prevent and detect infections. Baby aspirin is not indicated and may increase bleeding risk in leukemia.