Nokea
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
- A. The stool will be firm and well-formed.
- B. The stool will have a high volume of liquid.
- C. The stool will be similar to normal bowel movements.
- D. The stool will be hard and difficult to pass.
Correct Answer: B
Rationale: The correct answer is B: The stool will have a high volume of liquid. Following a colectomy with an ileostomy, the client will have fecal output from the small intestine, resulting in a high volume of liquid stool. This is because the large intestine, responsible for absorbing water and forming solid stool, is bypassed with an ileostomy. Choice A is incorrect because the stool will not be firm and well-formed. Choice C is incorrect because the stool will not be similar to normal bowel movements due to the absence of the large intestine. Choice D is incorrect as the stool will not be hard and difficult to pass.
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A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
- A. Close the pinch clamp on the CVC.
- B. Administer oxygen via non-rebreather mask.
- C. Place the client in Trendelenburg position.
- D. Obtain emergency IV access.
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (D) is not the first priority in this situation; preventing air embolism is critical.
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Wear a protective gown when suctioning the clients airway.
- B. Monitor for oral secretions every 2 hr.
- C. Provide oral care every 2 hr.
- D. Maintain the client in a supine position.
- E. Assess the client daily for readiness of extubation.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
- A. Inspect the pin sites at least every 8 hr.
- B. Apply direct pressure to pin sites.
- C. Remove traction weights for comfort.
- D. Encourage vigorous movement of the affected limb.
Correct Answer: A
Rationale: Correct Answer: A. Inspect the pin sites at least every 8 hr.
Rationale:
1. Inspecting pin sites regularly is crucial to monitor for signs of infection or other complications.
2. Postoperative clients with skeletal traction are at high risk for pin site infections.
3. Regular inspection allows early detection and intervention to prevent complications.
4. Waiting longer than every 8 hours may lead to delayed identification of issues.
Summary:
B. Applying direct pressure is contraindicated as it can cause harm.
C. Removing traction weights without medical order can lead to complications.
D. Encouraging vigorous movement is inappropriate and can cause harm.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A: A client who has a history of asthma. Propranolol is a non-selective beta-blocker that can potentially exacerbate bronchospasm in patients with asthma due to its mechanism of action. Therefore, the nurse should clarify the prescription with the provider before administering it to a client with asthma to avoid potential adverse effects. Choices B, C, and D are not contraindications for propranolol use, so there is no need to clarify the prescription for clients with hypertension, migraines, or stable angina.