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A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?
- A. We will give antidiarrheal medications.
- B. We will report signs of skin breakdown.
- C. We will give saline water enemas if my child doesn't pass stool.
- D. We will apply a heat lamp to any moist red tissue around the stoma.
Correct Answer: B
Rationale: The parents are instructed to report signs of skin breakdown or stomal complications, such as ribbonlike stools or failure to pass flatus or stools, to the primary health care provider or the nurse. Moist, red granulation tissue may grow around an ostomy site and does not require special treatment. The remaining options are incorrect actions and considered contraindicated.
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A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
- A. Reinforce the nursing assistant's use of this intervention over the bony prominence.
- B. Explain to the nursing assistant that massage is effective because it improves blood flow to the area.
- C. Inform the nursing assistant that massage is even more effective when combined with the use of lotion.
- D. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?
- A. Administer an antacid.
- B. Insert a nasogastric tube.
- C. Prepare for endoscopy.
- D. Administer a proton pump inhibitor.
Correct Answer: B
Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
- A. Administer an antiemetic.
- B. Prepare to insert a nasogastric (NG) tube.
- C. Collect data regarding recent client stressors.
- D. Place the client in a modified Trendelenburg position.
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.
The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take for long-term management?
- A. Allopurinol.
- B. Colchicine.
- C. Indomethacin.
- D. Prednisone.
Correct Answer: A
Rationale: Allopurinol reduces uric acid production for long-term gout management.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.