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 performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
- A. You will have a urinary catheter for several days.
- B. A PCA pump will be used for postoperative pain control.
- C. You will be discharged the same day as surgery.
- D. You should avoid all fluid intake after surgery.
Correct Answer: B
Rationale: The correct answer is B: A PCA pump will be used for postoperative pain control. This is crucial information for the client undergoing a radical prostatectomy as it ensures effective pain management post-surgery. The use of a PCA pump allows the client to self-administer pain medication within safe limits, promoting better pain control and comfort during the recovery period. It also empowers the client to actively participate in their pain management.
Choice A is incorrect because while the client may have a urinary catheter after surgery, it is not the most crucial information to include in preoperative teaching.
Choice C is incorrect as radical prostatectomy typically requires a hospital stay, not same-day discharge.
Choice D is incorrect as avoiding all fluid intake after surgery is not recommended; adequate hydration is important for recovery.
A nurse is assessing a client who has Cushings syndrome. Which of the following findings should the nurse expect?
- A. Osteoporosis
- B. Hypertension
- C. Weight loss
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. In Cushing's syndrome, excess cortisol weakens bones, leading to osteoporosis. B: Hypertension is common in Cushing's due to cortisol's effects on blood vessels. C: Weight gain, not loss, is typically seen in Cushing's due to cortisol-induced fat redistribution. D: Hyperglycemia, not hypoglycemia, is common due to cortisol's role in glucose metabolism. E, F, G are irrelevant. In summary, osteoporosis is expected due to cortisol's impact on bone health, while the other options are not typical findings in Cushing's syndrome.