Nokea
A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.
You may also like to solve these questions
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:
- A. Use benchmarking procedures to compare the findings with other nursing units in the hospital.
- B. Ask the staff education department to conduct an educational session about preventing pressure ulcers.
- C. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.
- D. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
Correct Answer: C
Rationale: A quality improvement plan addresses root causes, proposes solutions, and sets measurable outcomes, effectively reducing pressure ulcer incidence.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. In addition, the client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair after her bath, the client complains of severe pain and numbness in her left leg. The nurse should respond immediately by:
- A. Administering pain medication
- B. Assessing for edema in the left leg
- C. Assessing color and temperature of the left leg
- D. Encouraging the client to change her position
Correct Answer: C
Rationale: Severe pain and numbness post-hysterectomy suggest possible deep vein thrombosis (DVT) or arterial occlusion, common postoperative complications. Assessing color and temperature of the leg (e.g., pallor, coolness) helps identify circulatory compromise. Pain medication, edema assessment, or position change are less urgent.
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.