Nokea
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
Correct Answer:
Rationale: Correct Answer: B
Rationale: The correct location to assess the stoma following a transverse colon resection with colostomy placement is at location B, which is in the left lower quadrant. This is because the transverse colon is typically located in the upper abdomen, and the stoma would be brought out at the most dependent portion of the colon, which is in the left lower quadrant. Assessing the stoma in this location allows the nurse to monitor for proper stoma function and potential complications.
Summary:
A: Incorrect - Location A is in the right upper quadrant, which is not the typical site for a stoma following a transverse colon resection.
C: Incorrect - Location C is in the left upper quadrant, which is also not the typical site for a stoma after this surgery.
D, E, F, G: Not applicable as they are not relevant to the question.
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A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Phlebitis
Correct Answer: B
Rationale: The correct answer is B: Infection. When IV tubing is kinked, it can lead to a backflow of urine from the catheter into the tubing, increasing the risk of contamination and subsequent urinary tract infection. Additionally, when the urinary catheter bag is lying next to the client in bed, there is a higher chance of accidental contamination. Infections can lead to serious complications and require prompt intervention. Neurogenic bladder (A) is related to nerve damage affecting bladder control, not directly related to the current situation. Skin breakdown (C) may occur due to prolonged contact with urine but is not the immediate concern here. Phlebitis (D) is inflammation of a vein, not directly linked to the urinary catheter issue.
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
- A. Initiate airborne precautions
- B. Ensure the clients bed is positioned to greater than 45°
- C. Encourage frequent ambulation
- D. Ensure lights are dimmed in the clients room
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start IV with a large-bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start IV with a large-bore needle. This is the priority intervention because fluid resuscitation is crucial in managing burn injuries to prevent hypovolemic shock. Starting an IV line allows for prompt administration of fluids and medications. Administering analgesic medication (A) can wait until after fluid resuscitation. Increasing room temperature (B) is not a priority in burn management. Cleansing wounds (C) can be done after fluid resuscitation. Starting the IV line with a large-bore needle (D) takes precedence over other interventions to stabilize the client's condition.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chronic level
- B. Creatinine kinase
- C. Uric acid
- D. Immac factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in the production or decrease in the excretion of uric acid, leading to elevated levels in the blood. This results in the formation of urate crystals in the joints, causing inflammation and pain. Choices A, B, and D are unrelated to acute gout. A chronic level (Choice A) does not indicate an acute condition. Creatinine kinase (Choice B) is an enzyme related to muscle damage, not specific to gout. Immac factor (Choice D) is not a relevant marker for acute gout. Therefore, the correct answer is C as it directly correlates with the pathophysiology of acute gout.
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the feet.
- B. Keep the client's knees in a flexed position while they are in bed.
- C. Massage the client's legs every 4 hr while they are awake.
- D. Limit the client's fluid intake to 2
Correct Answer: A
Rationale: Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.