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 obligated to make a report for which situations? Select all that apply.
- A. Report to a client's employer that the client had a car crash while intoxicated
- B. Report to the authorities of a death by suicide on the unit
- C. Report to the client's spouse that the client has a reportable sexually transmitted disease
- D. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse
- E. Report to the supervisor that a health care provider has the smell of alcohol on the breath
Correct Answer: B,D,E
Rationale: Reporting is mandatory for suicides, suspected elder abuse, and impaired providers. Reporting to employers or spouses violates confidentiality.
The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel?
- A. Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client
- B. Please measure the Hemovac drainage at 2:00 PM and let me know how much there was.
- C. Please record the amount of Hemovac drainage on the intake and output record at the end of the shift
- D. Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught.
Correct Answer: A
Rationale: Changing a sterile dressing is a nursing task requiring sterile technique, inappropriate for unlicensed personnel. Measuring, recording, and compressing the Hemovac are within their scope.
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
- A. Gently rub the skin with a cotton swab to relieve itching
- B. Place the favorite books and push-pull toys in the crib
- C. Check every few hours for the next day or 2 for swelling in the baby's feet
- D. Turn the baby with the abduction stabilizer bar every 2 hours
Correct Answer: C
Rationale: Check every few hours for the next day or 2 for swelling in the baby's feet. A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to
- A. verify correct placement of the tube
- B. check that the feeding solution matches the dietary order
- C. aspirate abdominal contents to determine the amount of last feeding remaining in stomach
- D. ensure that feeding solution is at room temperature
Correct Answer: A
Rationale: verify correct placement of the tube. Proper placement of the tube prevents aspiration.