Nokea
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
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Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?
- A. Encouraging the intake of cranberry juice.
- B. Advising the client to eat large amounts of cheese.
- C. Establishing regular times for elimination.
- D. Having the client dangle at the bedside.
Correct Answer: D
Rationale: Dangling at the bedside is inappropriate, as it risks cast damage and improper positioning.
Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested?
- A. Ketoconazole suppresses adrenal steroid secretion.
- B. Ketoconazole destroys adrenocortical cells, resulting in a 'medical' adrenalectomy.
- C. Ketoconazole increases adrenocorticotropic hormone (ACTH)-induced corticosteroid serum levels.
- D. Ketoconazole decreases duration of adrenal suppression when administered with corticosteroids.
Correct Answer: A
Rationale: Ketoconazole inhibits adrenal steroid synthesis, reducing cortisol production, which can be therapeutic in Cushing's disease.
The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which of the following laboratory findings should cue the nurse to focus the client history assessment on specific drug or alcohol use?
- A. Total bilirubin, 0.3 mg/dL.
- B. Serum creatinine, 0.5 mg/dL.
- C. Hemoglobin, 16 g/dL.
- D. Folate, 1.5 ng/mL.
Correct Answer: D
Rationale: A serum vitamin B12 level of 800 pg/mL is within the normal range (200–900 pg/mL), but a folate level of 1.5 ng/mL is low (normal: 2.7–17 ng/mL). Low folate levels can be associated with chronic alcohol use, as alcohol impairs folate absorption and metabolism. The nurse should assess the client's history for alcohol use, as this may contribute to the folate deficiency. The other lab values (bilirubin, creatinine, hemoglobin) are normal and do not suggest drug or alcohol use.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help:
- A. Encourage formation of tough skin.
- B. Promote the growth of epithelial tissue.
- C. Provide for permanent wound closure.
- D. Facilitate development of subcutaneous tissue.
Correct Answer: B
Rationale: Porcine grafts act as a temporary biological dressing, promoting epithelial tissue growth by providing a protective barrier and stimulating healing. They do not form tough skin, provide permanent closure, or directly affect subcutaneous tissue.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize