Nokea
A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?
- A. Stoma that is red and moist
- B. Purulent drainage from the stoma
- C. Stoma that is dry and purple
- D. Mild swelling around the stoma
Correct Answer: C
Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.
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What is the priority intervention for a patient with fluid overload?
- A. Administer diuretics
- B. Administer IV fluids
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
A nurse is reviewing the results of an arterial blood gas analysis of a client who has chronic obstructive pulmonary disease. Which of the following results should the nurse expect?
- A. PaO2 of 95 mm Hg
- B. PaCO2 of 55 mm Hg
- C. HCO3 of 24 mEq/L
- D. pH level of 7.35
Correct Answer: B
Rationale: In chronic obstructive pulmonary disease, there is impaired gas exchange, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. A PaCO2 of 55 mm Hg is higher than the normal range (35-45 mm Hg) and is indicative of respiratory acidosis in COPD. Choices A, C, and D are not typically associated with COPD. PaO2 may be decreased, HCO3 may be elevated to compensate for acidosis, and pH may be lower than 7.35 due to respiratory acidosis in COPD.
A client is receiving a new prescription for enoxaparin. Which of the following instructions should the nurse include?
- A. Rub the injection site after administration.
- B. Pinch the skin while administering the injection.
- C. Aspirate before administering the medication.
- D. Avoid taking aspirin while using this medication.
Correct Answer: D
Rationale: The correct answer is D: 'Avoid taking aspirin while using this medication.' Enoxaparin is an anticoagulant medication, and taking aspirin concurrently can increase the risk of bleeding. Choices A, B, and C are incorrect. A nurse should not instruct the client to rub the injection site after administration as it may cause irritation. Pinching the skin while administering the injection is not recommended for enoxaparin injections. Aspirating before administering the medication is also unnecessary as enoxaparin is administered subcutaneously, not intramuscularly.
A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
- A. Avoid eating small, frequent meals.
- B. Sleep with the head of your bed elevated.
- C. Lie down after eating.
- D. Avoid drinking fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.