Nokea
A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?
- A. Change the ostomy appliance daily
- B. Empty the ostomy pouch when it is one-third full
- C. Rinse the ostomy pouch with warm water
- D. Apply a skin barrier to the peristomal skin
Correct Answer: B
Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.
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Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct Answer: C
Rationale: The correct answer is to record the findings on the flow sheet. These assessment findings are within normal limits for a 3-hour-old newborn. The axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate of 42 breaths/min are all expected in a newborn. No immediate intervention is needed, so the nurse should document these normal findings for future reference. Placing a pulse oximeter on the heel or swaddling the infant in a warm blanket is not indicated as the vital signs are within normal limits. Checking the vital signs in 15 minutes is unnecessary since the current findings are normal.
A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?
- A. Reddish-orange discoloration of body fluids
- B. Bloody or blood-tinged urine
- C. Blurring of vision
- D. Weight gain of more than 2 pounds in a week
Correct Answer: A
Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.
The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
- A. Administer the 20 Units of Humulin R subcutaneously as prescribed
- B. Ask the girl if she will be eating her breakfast this morning
- C. Discuss changing the insulin prescription to Lispro with the healthcare provider
- D. Explain to the mother the importance of eating the scheduled meals
Correct Answer: B
Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.
A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct Answer: D
Rationale: The maximum dosage the nurse should administer is 2 mg. This is calculated based on the prescription of 0.4 mg IM every 2 hours, not to exceed 5 doses. Since the medication is available in ampules containing 0.2 mg/ml, the nurse should administer 2 ml (0.2 mg/ml x 10 ml) for each dose, not exceeding 5 doses. Therefore, the nurse should limit the client's oral intake to 900 to 1,000 ml, to avoid exceeding the maximum dosage of 2 mg.
A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct Answer: D
Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.