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Questions 158

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Question 1 of 5

A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:

Correct Answer: D

Rationale: When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.

Question 2 of 5

A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?

Correct Answer: C

Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (
C) is not typically required unless in a sterile procedure.

Question 3 of 5

A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Correct Answer: C

Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.

Question 4 of 5

The physician has prescribed Oxycontin (oxycodone) for a client following an exploratory laparotomy. Which of the following is an adverse effect associated with the medication?

Correct Answer: C

Rationale: Oxycontin, an opioid, can cause nervousness or restlessness as a central nervous system side effect, alongside more common effects like sedation or respiratory depression. Pulmonary edema, increased blood pressure, and rapid pulse are not typical.

Question 5 of 5

The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

Correct Answer: B

Rationale: Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. Massaging the site of injection facilitates absorption of the insulin. Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.

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