Nokea
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
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The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
- A. Assisting with her daily hygiene activities.
- B. Lying flat in bed.
- C. Walking in the hall.
- D. Sitting all afternoon in her room.
Correct Answer: D
Rationale: Prolonged sitting stresses the surgical site and is contraindicated post-laminectomy.
The nurse is planning a staff development program related to infection control. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A?
- A. Gowning when entering a client's room.
- B. Wearing a mask when providing care.
- C. Assigning the client to a private room.
- D. Wearing gloves when giving direct care.
Correct Answer: D
Rationale: Hepatitis A is fecal-oral transmitted, so gloves (D) are essential during direct care to prevent contact with contaminated materials. Gowns (A), masks (B), and private rooms (C) are not required.
The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan?
- A. Have educational materials in large print
- B. Provide an eye patch to the affected eye
- C. Request food be seasoned with herbs
- D. Move closer to the better-hearing ear
Correct Answer: D
Rationale: Presbycusis is age-related hearing loss, so moving closer to the better-hearing ear facilitates communication. Large print materials and eye patches address vision issues, and herb-seasoned food is unrelated.
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client?
- A. You must shampoo your hair tonight to remove all oil and dirt.
- B. You may drink fluids until midnight, but after that drink nothing until the scan is completed.
- C. You will have some hair shaved to attach the small electrode to your scalp.
- D. You will need to hold your head very still during the examination.
Correct Answer: D
Rationale: Holding the head still during a CT scan is essential to obtain clear images. Shampooing, fasting, or shaving hair for electrodes are not required for a non-contrast head CT.
For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?
- A. Pain rating of 0 on a scale of 0 to 10 by the client.
- B. Respiratory rate of 26 breaths/minute.
- C. PaO2 of 70 mm Hg.
- D. None of the above
Correct Answer: A
Rationale: A pain rating of 0 indicates adequate pain control, enabling effective breathing. A respiratory rate of 26 is elevated, and a PaO2 of 70 mm Hg suggests mild hypoxemia, neither confirming pain control.