Nokea
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
- A. Taping a pouch that is leaking
- B. Cutting the skin barrier 1 1/2 inches larger than the stoma
- C. Changing the pouch only when leakage occurs
- D. Using a skin sealant under pouch adhesives
Correct Answer: D
Rationale: When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.
You may also like to solve these questions
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Abstract thinking
- B. Ability to focus and concentrate thoughts
- C. Judgment
- D. Memory
Correct Answer: B
Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperglycemia
- D. Hair loss
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
- A. Using sterile technique
- B. Applying suction for 20 seconds
- C. Instilling saline before suctioning
- D. Using a large-diameter catheter
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. Fresh fruit
- B. A milkshake
- C. Saltine crackers and peanut butter
- D. A ham and cheese sandwich
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C, D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.