Nokea
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
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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.
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply.
- A. If a client should develop crackles in their lung fields, it is a sign of a hemolytic reaction.
- B. Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals.
- C. Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure.
- D. It is important to ask the client about history of previous blood transfusions.
- E. Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion.
Correct Answer: A,E
Rationale: Crackles in the lung fields indicate transfusion-associated circulatory overload (TACO), not a hemolytic reaction, which typically presents with fever, chills, and hemoglobinuria. Pre-medication with diphenhydramine and acetaminophen is not always required, only when prescribed for clients with a history of allergic reactions. The other statements are correct: graft versus host disease is common in immunosuppressed clients, TACO is more likely in renal failure, and transfusion history is important.
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following?
- A. Induces sleep.
- B. Stimulates the client's appetite.
- C. Relieves muscular spasticity.
- D. Reduces the urine bacterial count.
Correct Answer: C
Rationale: Baclofen is a muscle relaxant used in MS to relieve spasticity, its primary therapeutic effect. It does not induce sleep, stimulate appetite, or reduce bacterial counts.
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
- A. The client assumes safe position when dizzy.
- B. The client experiences no falls.
- C. The client performs vestibular/balance exercises.
- D. The client demonstrates family involvement.
- E. The client keeps head still when dizzy.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.