Nokea
The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurse's best action?
- A. Administer an antibacterial agent and assess for additional signs of infection
- B. Document the findings and continue to monitor for changes
- C. Measure the stoma and obtain a larger pouching device
- D. Report the findings to the health care provider immediately
Correct Answer: D
Rationale: A bluish-gray stoma (D) indicates ischemia, requiring immediate reporting. Antibiotics (A) are premature, monitoring (B) delays care, and resizing the pouch (C) is irrelevant.
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The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
- A. A power of attorney (POA) is good to have in place. It sounds like you are on the right track.
- B. Great. Your POA can start to make decisions for you when you are no longer able to do so.
- C. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order.
- D. There are many types of POAs. Let's clarify if your POA can make health care decisions for you.
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (D) ensures proper advance directive planning. Vague affirmations (A, B) or suggesting a lawyer (C) do not address the need for a healthcare-specific POA.
The nurse is observing a nursing assistant move a client from bed to chair. Which action by the nursing assistant indicates a lack of understanding about transfer techniques?
- A. Bending from the waist when moving the person
- B. Keeping the feet separated when lifting and moving the person
- C. Turning the whole body when moving the person to the chair
- D. Asking for help in moving the person from bed to chair
Correct Answer: A
Rationale: Bending from the waist risks back injury, indicating improper technique. Wide stance, whole-body turning, and seeking help are correct.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.
A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?
- A. Crackers and cheddar cheese
- B. Hard-boiled egg with tomatoes
- C. Steamed fish and potatoes
- D. Tortilla chips with avocado dip
Correct Answer: C
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (A) to prevent hypertensive crisis. Fish and potatoes (C) are safe and nutritious. Eggs (B) and avocado (D) are safe but less balanced.