Nokea
What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
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A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply.
- A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
- B. Choose good calcium sources, such as figs, broccoli, and almonds.
- C. Use alcohol in moderation because a moderate intake has no known negative effects.
- D. None of the above
Correct Answer: A,B
Rationale: Vitamin D and calcium are essential for bone health. Excessive alcohol can reduce bone density, so moderation alone is insufficient.
The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position?
- A. Trendelenburg
- B. Supine
- C. Right lateral decubitus with head end elevated
- D. Prone
Correct Answer: B
Rationale: Supine position is appropriate for angle-closure glaucoma to avoid increasing intraocular pressure. Trendelenburg and prone positions may worsen pressure, and right lateral decubitus is not specific to this condition.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Slight rash.
- C. Worsening diarrhea.
- D. Fatigue.
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.