Nokea
A teaching plan developed by the nurse for the patient with a new ileal conduit includes instructions to do what?
- A. Clean the skin around the stoma with alcohol every day.
- B. Use a wick to keep the skin dry during appliance changes.
- C. Use sterile supplies and technique during care of the stoma.
- D. Change the appliance every day and wash it with soap and warm water.
Correct Answer: C
Rationale: The correct answer is C because using sterile supplies and technique during care of the stoma is crucial to prevent infection and promote healing. Cleanliness is essential in stoma care to avoid complications. Using a wick or changing the appliance every day may not be the most important aspect of caring for a new ileal conduit.
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During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of
- A. angina
- B. asthma
- C. hypertension
- D. rheumatoid arthritis
Correct Answer: C
Rationale: Hypertension is a common complication of renal insufficiency and is important to assess as it can impact the progression of the disease and treatment options.
The male patient is admitted with a diagnosis of benign prostatic hyperplasia (BPH). What urination characteristics should the nurse expect to assess in this patient?
- A. Oliguria
- B. Hesitancy
- C. Hematuria
- D. Pneumaturia
Correct Answer: B
Rationale: The correct answer is B because hesitancy is a common urination characteristic in patients with benign prostatic hyperplasia. Oliguria, hematuria, and pneumaturia are not typically associated with BPH.
An important point to remember when assisting urosto-mates with a pouch change is to
- A. scrub the peristomal skin with a deodorant soap
- B. cut the pouch opening approximately 3 mm larger than the stoma
- C. dry the skin thoroughly with alcohol wipes
- D. place aspirin in the bottom of the pouch to absorb odors
Correct Answer: B
Rationale: When assisting urosto-mates with a pouch change, it is important to cut the pouch opening approximately 3 mm larger than the stoma to prevent irritation and ensure a proper fit. This allows for a better seal and reduces the risk of leakage or skin damage. Scrubbing the peristomal skin with a deodorant soap, drying the skin with alcohol wipes, or placing aspirin in the pouch are not recommended practices and may lead to complications.
Water intoxication may result from absorption of excessive bladder irrigation solution after surgery. Which of the following symptoms might indicate water intoxication is developing?
- A. Confusion and restlessness
- B. Increased serum sodium concentration
- C. Cool, clammy skin
- D. Marked peripheral edema
Correct Answer: A
Rationale: Confusion and restlessness are common symptoms of water intoxication. Monitoring for these signs is crucial in detecting and managing water intoxication promptly to prevent further complications.
Which characteristic is more likely with acute pyelonephritis than with a lower UTI?
- A. Fever
- B. Dysuria
- C. Urgency
- D. Frequency
Correct Answer: A
Rationale: The correct answer is A because fever is more commonly associated with acute pyelonephritis, which is an infection of the renal parenchyma, compared to lower UTIs that primarily affect the bladder and urethra. Dysuria, urgency, and frequency can occur in both types of UTIs but may be more severe in acute pyelonephritis.