Nokea
A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would
- A. Assist the client in expressing feelings.
- B. Do most of the activities of daily living for the client.
- C. Provide information to the client only when the client requests it.
- D. Restrict visitors until the jaundice subsides.
Correct Answer: A
Rationale: The correct answer is A because assisting the client in expressing feelings shows empathy and addresses the client's emotional needs. It helps the client cope with the physical manifestations of the illness. Choice B is incorrect as it promotes dependence. Choice C is incorrect because providing information only upon request may not address the client's emotional distress. Choice D is incorrect as restricting visitors may further isolate the client.
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A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:
- A. Diarrhea related to alteration in bowel elimination.
- B. Impaired skin integrity related to seepage.
- C. Impaired nutrition: More than body requirements related to high-fat diet.
- D. Impaired physical mobility related to surgical procedure.
Correct Answer: B
Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing.
A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions.
C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance.
D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance.
In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.
A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site.
A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period.
C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage.
D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?
- A. Fatty foods
- B. Nonfat milk
- C. Chocolate
- D. Coffee
Correct Answer: B
Rationale: The correct answer is B: Nonfat milk. Nonfat milk is alkaline and can help increase lower esophageal sphincter pressure, reducing reflux symptoms. Fatty foods (A) can relax the sphincter and worsen symptoms. Chocolate (C) and coffee (D) are known triggers for reflux and can also decrease sphincter pressure. Therefore, the nurse would include nonfat milk in the teaching to help manage symptoms of gastroesophageal reflux disease.
The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?
- A. I can elevate the foot of the bed 4 to 6 inches.
- B. I can sleep on my stomach with my head turned to the left.
- C. I can sleep on my back without a pillow under my head.
- D. I can elevate the head of the bed 4 to 6 inches.
Correct Answer: D
Rationale: The correct answer is D: "I can elevate the head of the bed 4 to 6 inches." Elevating the head of the bed helps to prevent gastroesophageal reflux by promoting gravity to keep stomach acid from moving back into the esophagus. This position helps to keep the stomach contents in place and reduces the likelihood of reflux during sleep.
Choice A is incorrect because elevating the foot of the bed would not be effective in preventing reflux; it may even exacerbate the issue. Choice B is incorrect as sleeping on the stomach can increase pressure on the stomach and worsen reflux. Choice C is also incorrect as sleeping on the back without a pillow under the head may not provide the necessary elevation to prevent reflux effectively.
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer's
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.