Nokea
The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.
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A Stage II pressure ulcer is characterized by:
- A. Redness in the involved area.
- B. Muscle spasms in the involved area.
- C. Pain in the involved area.
- D. Tissue necrosis in the involved area.
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
- A. Send freshly-collected urine samples to the laboratory.
- B. Return the remainder of the blood component unit to the blood bank.
- C. Return the intravenous administration set to the blood bank.
- D. Alert Risk Management about the incident.
- E. Report the incident to the Infection Control Manager.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.
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.
Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.
- A. Violent vomiting.
- B. Severe diarrhea.
- C. Abdominal pain.
- D. Sensory neuropathy.
- E. Persistent cough.
Correct Answer: A,B,C
Rationale: Arsenic poisoning typically presents with acute gastrointestinal symptoms such as violent vomiting, severe diarrhea, and abdominal pain due to its toxic effects on the digestive system. Sensory neuropathy and persistent cough are less common immediate symptoms.