Nokea
Your client is receiving phototherapy. What nursing intervention would you implement for this client?
- A. Placing the client in the Trendelenburg position
- B. Monitoring the color of the stools
- C. Using a Hoyer lift for patient transfers
- D. Monitoring the arterial blood gases
Correct Answer: B
Rationale: Phototherapy, often used for jaundice, can affect stool color (e.g., green or loose stools in infants). Monitoring stool color helps assess treatment effects and complications.
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Which of the following personnel do not have the 'right to know' medical information?
- A. The facility's Performance Improvement Director who is not a healthcare person and who has no direct contact with clients
- B. A nursing student who is caring for a client under the supervision of the nursing instructor
- C. The facility's Safety Officer who is not a healthcare person and who has no direct contact with clients
- D. A department supervisor with no direct or indirect care duties
Correct Answer: A,C,D
Rationale: Personnel without direct or indirect client care responsibilities, such as the Performance Improvement Director , Safety Officer , and department supervisor , do not have a 'need to know' medical information under HIPAA, unless their role requires it.
The nurse evaluates a client's knowledge as deficient when the client makes which of the following statements about the drug dexamethasone (Decadron)?
- A. I cannot stop the Decadron all at one time.'
- B. If I forget a dose, it's no big deal; I'll just take it when I remember it.'
- C. When I get a cold, I need to let my doctor know.'
- D. I need to watch for an allergic reaction when I first start taking Decadron.'
Correct Answer: B
Rationale: Dexamethasone requires consistent dosing, and missing a dose can have significant effects, indicating a need for further instruction.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
A nurse is caring for a client with a new colostomy. Which of the following actions should the nurse include in the teaching plan to prevent skin breakdown around the stoma?
- A. Apply a skin barrier around the stoma
- B. Use soap to clean the stoma site
- C. Leave the pouch off for 2 hours daily
- D. Apply petroleum jelly to the stoma
Correct Answer: A
Rationale: A skin barrier protects the peristomal skin from irritation caused by stool. Soap can irritate the skin, leaving the pouch off risks exposure, and petroleum jelly is not recommended.
A client with a history of type 2 diabetes mellitus is prescribed pioglitazone (Actos). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypertension.
- D. Dry skin.
Correct Answer: B
Rationale: Pioglitazone can cause weight gain due to fluid retention, requiring monitoring in diabetic clients.