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Question 1 of 5

The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?

Correct Answer: D

Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.

Question 2 of 5

The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply.

Correct Answer: A,D

Rationale: Salt substitutes (potassium-based) can cause hyperkalemia with valsartan. Ethambutol can cause optic neuritis, requiring vision change reports. Levofloxacin with antacids reduces absorption. Sucralfate is taken before meals to coat the stomach. Rifampin's red-orange urine is normal, not reportable.

Question 3 of 5

The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?

Correct Answer: A

Rationale: Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal growth retardation.

Question 4 of 5

The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?

Question Image

Correct Answer: B

Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.

Question 5 of 5

The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.

Correct Answer: C,D,E

Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.

Similar Questions

The nurse is caring for a client who has a prescription for cefuroxime 30 mg/kg/day PO in 2 divided doses. The client weighs 35 lb (15.9 kg). The nurse has cefuroxime 250 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 1 decimal place.
A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply.
The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to
The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.
The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.

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