Nokea
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
- A. There is no odor from the stoma.
- B. The client is adequately hydrated.
- C. There is no skin irritation around the stoma.
- D. The client only changes the ostomy pouch once a day.
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
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Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply.
- A. Epstein-Barr virus.
- B. Human immunodeficiency virus (HIV).
- C. Cytomegalovirus (CMV).
- D. Hepatitis A.
- E. Malaria.
Correct Answer: B,C,E
Rationale: Blood transfusions, even from designated donors, carry a risk of transmitting certain diseases. HIV, CMV, and malaria are known to be transmissible through blood transfusions if the donor is infected, as these pathogens can persist in blood. Epstein-Barr virus is less commonly associated with transfusion transmission, and hepatitis A is primarily transmitted via the fecal-oral route, not blood. The nurse should inform the client of the risks of HIV, CMV, and malaria.
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
- A. Encourage the client to drink at least 1,000 mL per day.
- B. Provide parenteral rehydration therapy ordered by the physician.
- C. Turn and reposition every 2 hours.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize
The nurse is caring for a client prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply
- A. Diphenhydramine
- B. Acetaminophen
- C. 0.9% saline bolus
- D. Regular insulin
- E. Sodium bicarbonate
Correct Answer: A,B,C
Rationale: Amphotericin B infusions can cause infusion reactions and nephrotoxicity. Choice A (diphenhydramine) and Choice B (acetaminophen) are given to prevent infusion reactions like fever and chills. Choice C (0.9% saline bolus) helps protect the kidneys by ensuring adequate hydration. Choice D (insulin) and Choice E (sodium bicarbonate) are not routinely used.
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
- A. Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
- B. Assess the client for manifestations of pain.
- C. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom.
- D. Check to ascertain if any discrepancy had been documented with accompanying reason/s.
Correct Answer: A
Rationale: Validating with the outgoing RN confirms the morphine administration, ensuring safe timing of the next dose and preventing overdose.