Nokea
A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? Select all that apply.
- A. Client states, 'I will need home health to empty the pouch.'
- B. Client states, 'There is a little gas in the colostomy bag.'
- C. No bowel sounds are present and the client reports nausea
- D. Skin surrounding the stoma is red and excoriated
- E. Stoma is red, edematous, and smaller than the previous day
Correct Answer: C,D,E
Rationale: Absent bowel sounds with nausea suggest obstruction, red/excoriated skin indicates irritation, and a shrinking stoma may signal complications. Gas is normal, and needing home health is not inherently concerning.
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The nurse is assessing a client who had surgery 12 hours ago and is receiving IV morphine for incisional pain. It would require immediate follow-up if the client
- A. Has a blood pressure of 106/68 mm Hg
- B. Falls asleep while speaking with the nurse
- C. Reports burning at the IV site during administration of the medication
- D. Reports dizziness when getting out of bed to use the bathroom
Correct Answer: C
Rationale: Burning at the IV site suggests possible extravasation or phlebitis, which can lead to tissue damage or infection, requiring immediate intervention. Low blood pressure, falling asleep, and dizziness are less urgent and can be associated with morphine's expected effects.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
- A. Prevent insensible water loss.
- B. Provide a moist environment with oxygen at 30%.
- C. Prevent dehydration and reduce fever.
- D. Liquefy secretions and relieve laryngeal spasm.
Correct Answer: D
Rationale: A cool, high-humidity tent liquefies secretions and relieves laryngeal spasm in croup, easing breathing. It does not primarily prevent water loss, deliver 30% oxygen, or reduce fever.
While caring for a client with a pulmonary embolus, the nurse notes several petechiae on his chest and abdomen. Which action should the nurse take first?
- A. Apply ice packs to the area.
- B. Record the finding in the client's chart.
- C. Report the finding to the physician.
- D. Monitor the finding.
Correct Answer: C
Rationale: Petechiae may indicate a coagulopathy or emboli-related complication, requiring prompt reporting to the physician for further evaluation. Recording and monitoring are secondary, and ice packs are inappropriate.
A client who is diagnosed with breast cancer asks the nurse, 'Am I going to die?' Which statement by the nurse promotes a therapeutic relationship?
- A. Cancer is no longer a death sentence; you may live for many years.
- B. I will ask the chaplain to come and talk to you sometime today.
- C. Many people with cancer experience fear of dying; tell me about your concerns.
- D. Tell me about your life. What are your hopes and goals for the future?
Correct Answer: C
Rationale: This response validates the client's fear and invites further discussion, fostering trust and a therapeutic relationship. A offers reassurance but may dismiss the client's emotions. B deflects to another provider without addressing the concern. D shifts focus away from the client's immediate fear, missing the opportunity to explore their feelings.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.