Nokea
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
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Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Preventing constipation avoids straining, which could increaseSy to dislodge packing or cause bleeding. Showering is safe if precautions are taken. Coughing or nose-blowing could disrupt healing. The correct answer is based on preventing complications post-nasal surgery.
The nurse is preparing to insert a peripheral vascular access device. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply sterile dressing over the intravenous site.
- B. Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds.
- C. Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site.
- D. Insert the intravenous catheter at a 15 to 30 degree angle.
- E. Advance the catheter until a flash of blood is seen, then advance the catheter into the vein while removing the needle.
- F. Palpate vein at intended insertion site by pressing downward.
- G. Release tourniquet temporarily.
Correct Answer: C,F,G,B,D,E
Rationale: The correct order ensures proper vein selection, site preparation, catheter insertion, and securement while minimizing complications.
The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has measured the correct dose when the syringe reads how many units?
Correct Answer: 32 units.
Rationale: The total dose is 10 units regular + 22 units NPH = 32 units, which should be drawn into one syringe for administration.
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to:
- A. Keep the hands and feet elevated as much as possible
- B. Use a vibrating massage device on the hands
- C. Wear gloves when obtaining food from the refrigerator
- D. Increase coffee intake to 2 cups per day
Correct Answer: C
Rationale: Wearing gloves when obtaining food from the refrigerator prevents cold-triggered vasospasm in Raynaud's. Elevation is irrelevant, vibrating devices may worsen symptoms, and coffee (caffeine) can cause vasoconstriction, increasing episodes.
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
- A. Ask the client's wife to assist with the daily fluid intake to at least 2,500 mL.
- B. Respect the client's wishes and turn the client from side-to-side more frequently.
- C. Assess the client's reasons for refusing to deep breathe and cough.
- D. Explain the risks of not expanding the lungs and why the exercise is important.
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.