Nokea
A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take?
- A. Place ice packs around the stoma.
- B. Notify the surgeon about the stoma.
- C. Monitor the stoma every 30 minutes.
- D. Document stoma assessment findings.
Correct Answer: D
Rationale: The correct answer is D: Document stoma assessment findings. The rationale for this choice is that documentation is crucial in providing a clear and accurate record of the stoma's condition for ongoing monitoring and evaluation. By documenting the stoma assessment findings, the nurse can track any changes in color, edema, or drainage over time, which helps in identifying any potential issues or improvements.
Choice A is incorrect because placing ice packs around the stoma can cause vasoconstriction and worsen the edema. Choice B is unnecessary at this point as the nurse can first assess and document the stoma before escalating to the surgeon if needed. Choice C is not the best action as monitoring every 30 minutes may be excessive and not practical, especially if the patient is stable.
You may also like to solve these questions
The buildup of bile pigment in tissues that can be caused by gallstones is _____.
- A. hyperbilirubinemia
- B. obstructive jaundice
- C. hepatitis
- D. hepatocellular jaundice
Correct Answer: B
Rationale: The correct answer is B: obstructive jaundice. Gallstones can obstruct the bile duct, leading to the buildup of bile pigment in tissues, causing jaundice. This results in the characteristic yellowing of the skin and eyes. Hyperbilirubinemia (A) refers to elevated levels of bilirubin in the blood, which can occur in various liver conditions. Hepatitis (C) is inflammation of the liver, which can also lead to jaundice but is not directly caused by gallstones. Hepatocellular jaundice (D) is due to liver cell damage, not bile duct obstruction.
Although HAV antigens are not tested in the blood, they stimulate specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. Which antibody indicates there is acute HAV infection?
- A. Anti-HBc IgG
- B. Anti-HBc IgM
- C. Anti-HAV IgG
- D. Anti-HAV IgM
Correct Answer: D
Rationale: The correct answer is D: Anti-HAV IgM. IgM antibodies indicate acute infection as they are the first antibodies produced in response to a new infection. In the case of HAV, the presence of Anti-HAV IgM suggests recent exposure to the virus.
A: Anti-HBc IgG is not relevant to HAV infection. It indicates past or chronic hepatitis B infection.
B: Anti-HBc IgM is specific to hepatitis B infection, not HAV.
C: Anti-HAV IgG indicates past exposure or immunity to HAV, not acute infection.
Care for which of these clients is most appropriate to assign to the LPN/LVN, under the supervision of an RN?
- A. A client with oral cancer who is scheduled in the morning for glossectomy
- B. An obese client returned from surgery following a vertical banded gastroplasty
- C. A client with anorexia nervosa with muscle weakness and decreased urine output
- D. A client with intractable nausea and vomiting related to chemotherapy
Correct Answer: D
Rationale: The correct answer is D because the LPN/LVN can provide care for a client with intractable nausea and vomiting related to chemotherapy under the supervision of an RN. The LPN/LVN can administer prescribed antiemetic medications, monitor the client's response, assess for dehydration, and provide comfort measures. This task falls within the scope of practice for an LPN/LVN and does not require the advanced assessment and intervention skills of an RN.
Choice A is incorrect because a client undergoing a glossectomy for oral cancer requires complex post-operative care that is beyond the scope of practice for an LPN/LVN.
Choice B is incorrect because post-operative care for an obese client following a vertical banded gastroplasty involves monitoring for complications such as leaks or infections, which require the expertise of an RN.
Choice C is incorrect because a client with anorexia nervosa with muscle weakness and decreased urine output may have underlying medical issues that require an RN's assessment and intervention skills
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient asks about the best way to prevent respiratory infections. What is the nurse's best response?
- A. "Take a yearly flu shot and avoid crowds during flu season."
- B. "Increase your use of nebulizer treatments to keep your lungs clear."
- C. "Take vitamin C to boost your immune system."
- D. "Use an antibiotic regularly to prevent infections."
Correct Answer: A
Rationale: Step 1: The nurse's response should focus on preventing respiratory infections in a patient with COPD.
Step 2: Yearly flu shots are recommended to prevent influenza, a common trigger for respiratory infections in COPD.
Step 3: Avoiding crowds during flu season reduces exposure to pathogens, further preventing infections.
Step 4: Increasing nebulizer treatments does not directly prevent infections but may help manage COPD symptoms.
Step 5: Vitamin C may have some benefits but is not a primary preventive measure for respiratory infections in COPD.
Step 6: Regular antibiotic use is not recommended to prevent infections due to the risk of antibiotic resistance and potential side effects.
Conclusion: Option A is the best response as it includes evidence-based strategies to prevent respiratory infections in a patient with COPD.
Which patient has the highest risk for poor nutritional balance related to decreased ingestion?
- A. Tuberculosis infection
- B. Draining decubitus ulcers
- C. Malabsorption syndrome
- D. Severe anorexia resulting from radiation therapy
Correct Answer: D
Rationale: The correct answer is D: Severe anorexia resulting from radiation therapy. This patient has the highest risk for poor nutritional balance due to the severe anorexia caused by the treatment. Radiation therapy often leads to loss of appetite, making it difficult for the patient to ingest adequate nutrients, resulting in malnutrition.
A: Tuberculosis infection does not necessarily directly cause decreased ingestion, as appetite may vary among patients.
B: Draining decubitus ulcers may lead to protein and fluid loss but not necessarily decreased ingestion.
C: Malabsorption syndrome affects the absorption of nutrients but does not directly relate to decreased ingestion.