Nokea
The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?
- A. Consult with the wound care nurse specialist
- B. Insert a rectal tube to contain the feces
- C. Provide perianal skin care with barrier cream
- D. Use incontinence briefs to protect the skin
Correct Answer: C
Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.
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The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
- A. An excess of red blood cells
- B. An excess of white blood cells
- C. A deficiency of clotting factor VIII
- D. A deficiency of clotting factors VIII and IX
Correct Answer: C
Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
- A. Anger
- B. Helplessness
- C. Calm
- D. Explosiveness
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.
A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?
- A. He should take all regularly scheduled medications.
- B. Antihypertensives should not be taken before dialysis because the blood pressure drops during dialysis.
- C. He should check with the physician because it varies from person to person.
- D. He should take it with him and take it if his blood pressure rises during the treatment.
Correct Answer: B
Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.
The nurse has reinforced teaching with the parent of a pediatric client with newly diagnosed hemophilia A. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using icepacks if my child is injured.
- B. I should provide a high-fat, high-protein diet for my child.
- C. My child should wear emergency medical identification at all times.
- D. My child can participate in noncontact sports such as swimming.
- E. I should avoid giving my child medication containing aspirin.
Correct Answer: C,D,E
Rationale: Medical identification ensures prompt treatment in emergencies. Noncontact sports like swimming are safe. Aspirin increases bleeding risk and should be avoided. Ice packs are beneficial for injuries to reduce swelling, and diet doesn't require high-fat/protein for hemophilia management.
The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.
- A. Seek emotional support from a trusted source.
- B. Consult the facility's sexual harassment policy.
- C. Report the behavior to the supervisor immediately.
- D. Document each occurrence according to facility policy.
- E. Confront the HCP outside the workplace about the behavior.
Correct Answer: A,B,C,D
Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.