REX-PN Exam 2024 with 100%Correct Answers.
1. the nurse is caring for a client with Caron's disease who develops a fever
and symptoms of a urinary
... [Show More] tract infection (UTI) with tan, feral-smelling urine.
which of the following information should the nurse teach the client?
a. about the effects of corticosteroid use on immune function
b. to empty the bladder before and after sexual intercourse
c. about fistula formation between the bowel and bladder
d. to clean the perineal area carefully after any stools: c. about fistula formation
between the bowel and bladder
rationale: fistulas between the bowel and bladder occur in chrons disease and can
lead to UTI. there is no information indicating that the client's risk for UTI is caused bypoor cleaning or not voiding before and after intercourse. steroid use may increase
the risk for infection, but the characteristics of the client's urine indicate that a fistula
has occurred.
2. during the initial postoperative assessment of a clients stoma formed from a transverse colostomy. the nurse finds it to be deep pink with moderate oedemaand a small amount of bleeding. which of the following actions should the
nurse take based upon these findings?
a. place an ice pack on the stoma to reduce swelling
b. notify the surgeon about the stoma appearance
c. document the stoma assessment
d. monitor the stoma every 30 minutes: c. document the stoma assessment
rationale: the stoma appearance indicates good circulation to the stoma. there is no
indication that surgical intervention is needed or that frequent stoma monitoring is
required. swelling of the stoma is normal for 2-3 weeks after surgery and an ice pack is not needed.
3. the home health nurse is providing teaching a clients and family about
how to use glargine and regular insulin safely. Which of the following nursing
actions by the client indicated that the teaching has been successful?
a. the client administers glargine 30-45 minutes before eating each meal
b. the client's family fills the syringes weekly and stores them in the refrigerator
c. the client draws up the regular insulin and then glargine in the same syringe d. the client disposes of the open vial of glargine and regular insulin after 4
weeks: d. the client disposes the open vials of glargine and regular insulin after 4
REX-PN Exam 2024 with 100%Correct Answers
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weeks
rationale: insulin can be stored at room temperature for 4 weeks. glargine should not be mixed with other insulins or pre-filled and stored. short acting regular insulin is
administered before meals, while glargine is given once daily.
4. a client is suspected of having a pituitary tumour causing panhypopituitarism. during assessment of the client, which of the following findings
should the nurse anticipate?
a. high blood pressure
b. changes in secondary sex characteristics
c. elevated blood glucose: b. changes in secondary sex characteristics
5. which of the following information about a client who has just been admittedto the hospital with nausea and vomiting requires the most rapid intervention
by the nurse?
a. the client has taken only sips of water
b. the client has been vomiting for several times a day for the last 4 days
c. the client is lethargic and difficult to arouse
d. the clients chart indicates a recent reaction of the small intestine: c. the clientis lethargic and difficult to arouse
rationale: a lethargic client is at risk for aspiration, and the nurse will need to position the client to decrease aspiration risk. the other information also is important to
collect, but it does not require as quick action as the risk for aspiration.
6. the nurse is caring for a client with Crohn's disease who has megaloblastic
anemia. which of the following medications should the nurse anticipate teaching the client about taking on an ongoing basis?
a. regular blood transfusions
b. cobalamin (B12) nasal spray or injections
c. oral ferrous sulphate tablets
d. iron dextran (imferon) infusion: b. cobalamin (B12) nasal spray or injections
rationale: Crohn's disease frequently affects the ileum. where absorption of cobalamin occurs, and it must be administered regularly by nasal spray or IM to correct
the anemia. iron deficiency does not cause megaloblastic anemia. the client may
need occasional transfusion but not regularly scheduled transfusions.
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7. the health care provider prescribes antacids for treatment of a clients peptic ulcer. which of the following information should the nurse include in the clientsteaching plan?
a. sucralfate and antacids together 30 minutes before each meal
b. antacids after eating and sucralfate 30 minutes before eating
c. sucralfate at bedtime and antacids before meals
d. antacids 30 minutes before the sucralfate: b. antacids after eating and sucralfate 30 minutes before eating
rationale: sucralfate is most effective when the pH is low and should not be given
with or soon after an antacid. antacids are most effective when taken after eating.
administration of sucralfate 30 minutes before eating will ensure that both drugs
can be the most effective. the other regimens will decrease the effectiveness of the
medications
8. the nurse is caring for a client who has an adrenocortical adenoma and
hyperaldosteronism. which of the following actions should the nurse implement?
a. evaluate blood glucose level every 4 hours
b. monitor the blood pressure every 4 hours
c. maintain extremities in an elevated position
d. provide a potassium-restricted diet: b. monitor the blood pressure every 4
hours
hypertension caused by sodium retention is a common complication of hyperaldosteronism. hyperaldosteronism does not cause an elevation in blood glucose. the
client will be hypokalemic and require potassium supplementation before surgery.
edema does not usually occur hyperaldosteronism. [Show Less]