Nokea
The nurse is caring for a client with a new colostomy.
- A. What is the most appropriate teaching point for a client with a new colostomy?
- B. Change the appliance every morning.
- C. Empty the pouch when it is one-third full.
- D. Use a mild soap to cleanse the peristomal skin.
- E. Apply a skin barrier only if irritation occurs.
Correct Answer: C
Rationale: Using a mild soap to cleanse the peristomal skin prevents irritation and maintains skin integrity. Changing the appliance daily is unnecessary, emptying at one-third full prevents leaks, and a skin barrier should be used routinely to protect the skin.
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The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
The nurse is caring for a client who is ordered to be on bed rest for a prolonged period of time. What should be included in the nursing care plan to prevent venous stasis?
- A. Deep breathe and cough every two hours
- B. Range-of-motion exercises every shift
- C. Antiembolism stockings on legs
- D. Turn every two hours
Correct Answer: C
Rationale: Antiembolism stockings promote venous return, preventing stasis in bedridden clients. Breathing exercises, ROM, and turning address other complications but not venous stasis directly.
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
- A. The client's arms and legs are exercised every day.
- B. The daughter gets her mother out of bed several times a day.
- C. The client is given a shower every other day.
- D. The daughter puts the chair on the right side of the bed when getting her mother out of bed.
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
Which of the following infants is in need of additional growth assessment?
- A. Baby girl A: age 4 months, BW 7 lbs. 6 oz., present weight 14 lbs. 14 oz.
- B. Baby girl B: age 2 weeks, BW 6 lbs. 10 oz., present weight 6 lbs. 11 oz.
- C. Baby girl C: age 6 months, BW 8 lbs. 9 oz., present weight 15 lbs. 0 oz.
- D. Baby girl D: age 2 months, BW 7 lbs. 2 oz., present weight 9 lbs. 10 oz.
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.