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Questions 164

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Question 1 of 5

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

Correct Answer: C

Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.

Question 2 of 5

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

Correct Answer: A,C

Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.

Question 3 of 5

A client is admitted for COPD. Which findings would require the nurse's immediate attention?

Correct Answer: B

Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.

Question 4 of 5

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.

Correct Answer: A,C,E

Rationale: Inspecting the home identifies lead sources (e.g., paint, dust). Frequent hand washing reduces ingestion of lead dust. Follow-up testing monitors levels. Vacuuming may spread lead dust; wet mopping is preferred. Hot water can leach lead from pipes; cold water is safer.

Question 5 of 5

The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?

Correct Answer: B

Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.

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