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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A client with renal calculi is prescribed potassium citrate. The purpose is to:
- A. Dissolve stones.
- B. Alkalinize urine.
- C. Reduce pain.
- D. Prevent bleeding.
Correct Answer: B
Rationale: Potassium citrate alkalinizes urine, preventing uric acid stone formation.
A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.
- A. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock.
- B. Administers immediate-release medication (oxycodone) for breakthrough pain.
- C. Avoids long-acting opioids due to her concern about addiction.
- D. Uses music for distraction as well as heat or cold in combination with medications.
- E. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications.
- F. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal.
Correct Answer: A,B,D,F
Rationale: Effective pain management includes around-the-clock long-acting opioids (A), immediate-release opioids for breakthrough pain (B), non-pharmacologic methods like music or heat/cold (D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- A. Stabilize the leg with Buck's traction.
- B. Apply an ice pack to the affected hip.
- C. Position the client toward the opposite side of the hip.
- D. Notify the orthopedic surgeon.
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
- A. Assess respiratory status.
- B. Draw blood for laboratory studies.
- C. Insert a Foley catheter.
- D. Weigh the client.
Correct Answer: A
Rationale: Edema and left ventricular enlargement suggest heart failure, which can cause pulmonary edema. Assessing respiratory status first detects signs of respiratory distress.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
- A. Dust particles.
- B. Droplet nuclei.
- C. Water.
- D. Eating utensils.
Correct Answer: B
Rationale: Tuberculosis is primarily spread through droplet nuclei produced when an infected person coughs or sneezes. Dust, water, and utensils are not significant transmission routes.