Nokea
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.
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The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?
- A. Checking the flow rate
- B. Monitoring the vital signs
- C. Identifying the client
- D. Maintaining blood temperature
Correct Answer: C
Rationale: The primary nursing intervention in the administration of blood is to correctly identify the client. This is crucial to ensure that the right blood is being administered to the right patient to prevent transfusion reactions and ensure patient safety. Before any blood transfusion, the nurse must verify the patient's identity using at least two unique identifiers, such as name, date of birth, and hospital or medical record number. Patient safety hinges on this critical step, making it the priority when administering blood products. While monitoring vital signs, checking the flow rate, and maintaining blood temperature are all important aspects of blood transfusion management, identifying the client is fundamental and must come first to prevent errors.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.
With pulmonary edema, there is usually an alteration in:
- A. Afterload
- B. Preload
- C. Contractility
- D. All of the above
Correct Answer: D
Rationale: Pulmonary edema is characterized by the accumulation of excess fluid in the lungs, which can lead to impaired gas exchange and respiratory distress. In the presence of pulmonary edema, there is usually an alteration in all three factors mentioned: afterload, preload, and contractility.
recurrent urinary tract infection in children cause:
- A. arthritis
- B. recurrent rash
- C. growth disturbance
- D. behavioral disturbances
Correct Answer: C
Rationale: Recurrent urinary tract infections (UTIs) in children can potentially cause growth disturbance. UTIs in children can result in poor weight gain, failure to thrive, and reduced height due to the stress and inflammatory response on the body. Chronic inflammation from recurrent UTIs can affect a child's overall health and development, leading to growth disturbances. It is essential to promptly treat and prevent recurrent UTIs in children to avoid potential long-term complications such as growth disturbances. Arthritis, recurrent rash, and behavioral disturbances are not typically associated with recurrent UTIs in children.