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 at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider?
- A. The client ate a full breakfast that morning
- B. The client has an implantable cardiovascular defibrillator (ICD)
- C. The client is allergic to povidone-iodine
- D. The client took all prescribed cardiac medications before arriving
Correct Answer: B
Rationale: An ICD is a contraindication for MRI due to magnetic interference, requiring immediate reporting. Other findings are less critical.
The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?
- A. A 2-year-old eating a hot dog unsupervised
- B. A 3-year-old playing alone in a wading pool
- C. A 4-year-old tossing a beach ball
- D. A 5-year-old climbing on monkey bars
Correct Answer: B
Rationale: A 3-year-old alone in a wading pool is at immediate risk of drowning, requiring urgent intervention. A poses a choking risk but is less immediately life-threatening. C and D are age-appropriate activities with lower immediate risk.
There is a train wreck causing 46 casualties. The nurse is asking personnel on the floor to suggest clients who could be discharged to make room for casualties. Which client would be best for the LPN to suggest?
- A. A 77-year-old who had a fractured femur with hip replacement yesterday
- B. A 58-year-old who had an open cholecystectomy two days ago
- C. A 52-year-old who had a bowel resection with colostomy yesterday
- D. A 44-year-old who is undergoing internal radiation for cancer of the cervix
Correct Answer: B
Rationale: The client who had an open cholecystectomy two days ago is likely stable and closer to discharge compared to those with recent major surgeries or ongoing radiation, which require specialized care.
The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with
- A. carpal tunnel syndrome
- B. small cell lung cancer
- C. osteomyelitis
- D. sciatica
Correct Answer: B
Rationale: Small cell lung cancer is strongly associated with SIADH due to ectopic ADH production. Other conditions listed are not significant risk factors.
The LPN on a medical unit observes a coworker taking diazepam ordered for a client. What should the nurse do initially?
- A. Immediately call the supervisor
- B. Confront the nurse
- C. Observe the nurse for unsafe behavior
- D. Administer that nurse's medications for the rest of the shift
Correct Answer: C
Rationale: Observing for unsafe behavior assesses immediate risk to patients, allowing appropriate reporting if impairment is confirmed.