Nokea
When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?
- A. Antiseptic cream
- B. Petroleum jelly
- C. Cornstarch
- D. Stomadhesive
Correct Answer: D
Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.
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While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?
- A. Swab the oral cavity with a washcloth
- B. Use oral swabs with normal saline
- C. Provide a Yankauer tip for oral suction
- D. Support the head with a small pillow
Correct Answer: B
Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.
The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?
- A. Glucose should be taken if I have a fruity breath odor.
- B. Glucose should be taken if I am urinating more than usual.
- C. Glucose should be taken if I have blurred vision.
- D. Glucose should be taken if I develop shakiness.
Correct Answer: D
Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.
The nurse is performing a psychosocial assessment on an adolescent aged 14. Which emotional response is typical during early adolescence?
- A. Frequent anger
- B. Cooperativeness
- C. Moodiness
- D. Combativeness
Correct Answer: C
Rationale: Moodiness is a typical emotional response during early adolescence. Hormonal changes and developmental challenges contribute to this behavior. While anger and combativeness can also be present during adolescence, they are not as consistently typical as moodiness. Cooperativeness, on the other hand, is a trait more commonly associated with later stages of development and maturity, rather than early adolescence.
During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?
- A. Slight increase in blood pressure
- B. Elevated temperature and chills
- C. Mild nausea
- D. Slight headache
Correct Answer: B
Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.
Which electrolyte imbalance is most commonly associated with seizures?
- A. Hyponatremia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.