NCLEX-PN - Med surgical Questions and Answers 100% Pass

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NCLEX-PN - Med surgical Questions and Answers 100% Pass A client with cirrhosis is being discharged home, with family members to provide the majority of the client's care. Which instructions are im... portant to reinforce with the family regarding this client's care? (Select all that apply.) a. Maintain a low-fiber diet. b. Use a safety razor to shave the client. c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently. ✔✔c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently. Rationale: A client with cirrhosis often has dry itchy skin. Soap can dry and irritate the skin further. To prevent skin breakdown, the skin should be kept moist and the client turned frequently. With cirrhosis, the liver is not able to produce some clotting factors, so bleeding prevention is a priority. The family should be instructed to use electric razors, not a safety razor, and to use a soft toothbrush when providing gentle oral care. The practical nurse (PN) is reinforcing colostomy care teaching to a client who is 3 days following placement of their colostomy. The client asked the PN why is it necessary to measure the colostomy's stoma each time when changing into a new appliance/wafer. What is the best response by the PN? a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Inform the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure. ✔✔b. Inform the client that the stoma will become smaller when the initial swelling diminishes. Rationale: Postoperative swelling causes enlargement of the stoma. The PN needs to reinforce to the client that the stoma will become smaller when the swelling is diminished. This is necessary in order to prevent irritation to the surrounding skin from the colostomy's drainage (effluent). The purpose of the colostomy appliance is to provide a protective barrier surrounding the stomal skin, along with containing effluent from the colostomy. The nurse is caring for a female client who has human immunodeficiency virus (HIV) infection. Which aspects does the nurse expect to see included in the plan of care? (Select all that apply.) a. The breastfeeding mother should continue breastfeeding to provide the infant with the appropriate nutrients. b. The client should be educated that cervical cancer is more likely to occur in a client with an HIV infection. c. The client should be educated to report symptoms such as confusion, and any disturbances in vision. d. The client should not be assigned to a nurse or any other care provider who is pregnant or is breastfeeding. e. The client should be educated that dogs, especially those previously in a shelter, should not be brought into the home. ✔✔b. The client should be educated that cervical cancer is more likely to occur in a client with an HIV infection. c. The client should be educated to report symptoms such as confusion, and any disturbances in vision. Rationale: Cervical dysplasia is more likely to occur in a client with an HIV infection. Confusion and a disturbance in vision are associated with opportunistic infections and should be reported to the health care provider as soon as possible. The client should be educated not to breastfeed, as the virus can be transmitted to the infant in this manner. Nurses and other caregivers should use universal precautions with any client, not just those clien [Show More]

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