Nokea
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
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A child with thrush has been prescribed fluconazole (Diflucan). The child's mother asks what this medication is used for, and the nurse correctly replies,
- A. This is an antiviral medication used to treat your child's viral infection.'
- B. This medication is used to treat yeast infections.'
- C. This medication is an analgesic that will ease your child's pain while eating.'
- D. This is an antibiotic for your child's bacterial infection.'
Correct Answer: B
Rationale: Fluconazole is an antifungal used to treat thrush, a yeast infection caused by Candida.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: safety is a priority for the client who is at high risk for infection
The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find:
- A. An apical pulse of 100
- B. An absence of tonus
- C. Cyanosis of the feet and hands
- D. Jaundice of the skin and sclera
Correct Answer: C
Rationale: Acrocyanosis (cyanosis of hands and feet) is normal in newborns at 1 minute due to immature circulation.
Which of the following are controlled substances (Schedules I through V) regulated by the Drug Enforcement Agency (DEA)? Select all that apply.
- A. Codeine
- B. Ibuprofen
- C. Diphenhydramine (Benadryl®)
- D. Hydrocodone
Correct Answer: A,D
Rationale: Codeine (A) and hydrocodone (D) are DEA-controlled substances (Schedules II-V). Ibuprofen (B) and diphenhydramine (C) are not controlled.
The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
- A. Have you noticed a change in sleeping habits recently?
- B. Have you had a respiratory infection in the last 6 months?
- C. Have you lost weight recently?
- D. Have you noticed changes in your alertness?
Correct Answer: C
Rationale: Unexplained weight loss is a common symptom of leukemia due to increased metabolic demand and systemic effects of the disease.