Nokea
Which of the following skin preparations would be best to apply around the client's colostomy?
- A. Karaya.
- B. Petroleum jelly.
- C. Antiseptic cream.
- D. None of the above
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply
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Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
- A. A 4-year-old cocker spaniel.
- B. Scatter rugs.
- C. Snack tables.
- D. Rocking chairs.
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
Which outcome is appropriate for a client with a traumatic brain injury?
- A. Complete memory recovery.
- B. Active participation in therapy.
- C. Return to pre-injury job.
- D. Eliminate all symptoms.
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.