Nokea
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.
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The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
- A. I should tell my child to ride their bike against the traffic pattern.
- B. I should instruct my child to walk their bike through busy intersection crosswalks.
- C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
- D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B
Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.
The nurse is caring for a client who has rubella. To prevent the spread of infection, which transmission-based precaution should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: Rubella requires droplet precautions due to respiratory transmission.
The nurse is teaching a client with hypothyroidism. The nurse should recommend that the client increase their intake of foods rich in
- A. Fiber.
- B. Saturated fats.
- C. Calcium.
- D. Potassium.
Correct Answer: A
Rationale: Fiber aids digestion, often slowed in hypothyroidism. Saturated fats, calcium, and potassium are not specifically indicated.