Nokea
The nurse observes that a client's ileostomy output is green and watery. Which action should the nurse take first?
- A. Notify the physician immediately.
- B. Document the finding as normal.
- C. Increase the client's fiber intake.
- D. Administer an antidiarrheal medication.
Correct Answer: B
Rationale: Green, watery output is normal for an ileostomy, especially early post-surgery, and should be documented. Notifying the physician, increasing fiber, or giving antidiarrheals are unnecessary unless other symptoms arise. CN: Physiological adaptation; CL: Synthesize
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The nurse is planning a staff development conference about medication reconciliation. Which of the following information should the nurse include?
- A. Obtain a list of the medications instead of reviewing the list with the client
- B. Medication reconciliation should occur just at discharge to prevent omissions.
- C. Prescribed medications should be obtained and omit herbs and supplements.
- D. This process should occur at admission, client transfer, and discharge.
Correct Answer: C
Rationale: Medication reconciliation at admission, transfer, and discharge ensures accuracy and continuity of care.
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
- A. Provide access for wound irrigation.
- B. Promote drainage of wound exudate.
- C. Minimize development of scar tissue.
- D. Decrease postoperative discomfort.
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?
- A. Skin turgor.
- B. Temperature.
- C. Thirst.
- D. Daily weight.
Correct Answer: D
Rationale: Daily weight reflects fluid balance, which is influenced by glucocorticoid and mineralocorticoid replacement in Addison's disease.
A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this drug? Select all that apply.
- A. Nausea.
- B. Rash.
- C. Constipation.
- D. Flushed skin.
- E. Bone marrow depression.
Correct Answer: A,B,E
Rationale: Nausea, rash, and bone marrow depression are known adverse effects of allopurinol, indicating potential toxicity or allergic reactions.
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
- A. Help keep him well hydrated.
- B. Dissolve clots that he may have.
- C. Prevent kidney failure.
- D. Treat potential cardiac arrhythmias.
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.