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Questions 149

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Question 1 of 5

The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?

Correct Answer: C

Rationale: Stomahesive provides effective skin protection around the ileostomy, preventing irritation and ensuring a secure seal.

Question 2 of 5

A nursing student is assigned to a client with an endotracheal tube on a ventilator. Upon entering the client's room the primary care nurse is alerted by observing which of the following?

Correct Answer: C

Rationale: Normal saline at the bedside may indicate improper suctioning practices, as it’s not recommended for routine endotracheal suctioning, posing a risk for infection.

Question 3 of 5

A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:

Correct Answer: C

Rationale: Protein-rich snacks help maintain nutritional status and support liver function in cirrhosis, while sodium should be limited to reduce ascites.

Question 4 of 5

A client has been prescribed tetracycline (Sumycin) for Lyme disease. All of the following statements indicate successful client teaching regarding this medication EXCEPT

Correct Answer: A

Rationale: Tetracycline should not be taken with antacids, as they reduce absorption. The other statements are correct: pregnancy is a contraindication, photosensitivity requires sunscreen, and dairy products interfere with absorption.

Question 5 of 5

A client with hyperkalemia is admitted to the telemetry unit. Which of the following would require notification of the health care provider? Select all that apply.

Correct Answer: A, B

Rationale: Spiked T waves and bradycardia (heart rate 53) are signs of severe hyperkalemia, requiring immediate provider notification. Normal heart rate, food refusal, and adequate urinary output (30 cc/hr) are not urgent.

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