Nokea
A nurse is caring for a client with a new colostomy. Which of the following actions should the nurse include in the teaching plan to prevent skin breakdown around the stoma?
- A. Apply a skin barrier around the stoma
- B. Use soap to clean the stoma site
- C. Leave the pouch off for 2 hours daily
- D. Apply petroleum jelly to the stoma
Correct Answer: A
Rationale: A skin barrier protects the peristomal skin from irritation caused by stool. Soap can irritate the skin, leaving the pouch off risks exposure, and petroleum jelly is not recommended.
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The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?
- A. Bradycardia.
- B. Sudden chest pain.
- C. Hypotension.
- D. Fever.
Correct Answer: B
Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
- A. Epidural catheter
- B. Hickman catheter
- C. Central venous catheter (CVC)
- D. Patient-controlled analgesia (PCA) pump
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.
A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Mirtazapine commonly causes weight gain.
Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
A client has been taking lisinopril for 3 months. The client reports to the nurse a persistent dry cough that began about 1 month ago. The nurse interprets that the most likely reason for the client's complaint is what?
- A. Neutropenia as a result of therapy
- B. An expected side effect of therapy
- C. Undiagnosed existence of heart failure
- D. A concurrent upper respiratory infection
Correct Answer: B
Rationale: A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the primary health care provider if the cough becomes very troublesome to them. The other options are incorrect interpretations.