Nokea
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
- A. Is the opening on the client's left side
- B. Is the opening on the distal end on the client's left side
- C. Is the opening on the client's right side
- D. Is the opening on the distal right side
Correct Answer: C
Rationale: The proximal end of a double-barrel colostomy, which produces stool, is typically on the client's right side.
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The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with methcillin resistant-staphylococcus aureas (MRSA)
- B. The client with diabetes
- C. The client with pancreatitis
- D. The client with Addison's disease
Correct Answer: A
Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.
A client recently diagnosed with atrial fibrillation is being discharged home on digoxin (Lanoxin). The nurse is providing education to the client and family. Which client statement indicates the need for further teaching?
- A. I should take my medicine at the same time each day.
- B. If I miss a dose, I can take it as soon as I remember it.
- C. I need to call my doctor if my heart rate goes below 60 or above 110.
- D. Changes in my vision could be toxicity and should be reported immediately.
Correct Answer: B
Rationale: Taking a missed digoxin dose as soon as remembered is incorrect; clients should skip it if it’s close to the next dose to avoid toxicity. Other statements reflect correct understanding.
Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
- A. Fever
- B. Red urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.
A client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What medication would the nurse prepare for initial administration?
- A. Atropine
- B. Verapamil (Calan)
- C. Lidocaine (Xylocaine)
- D. Procainamide (Pronestyl)
Correct Answer: A
Rationale: Third-degree AV block with hypotension (BP 78/40) requires atropine to increase heart rate by blocking vagal activity, improving cardiac output.
A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?
- A. Notify the physician of readings less than 3 cm or more than 8 cm of water
- B. Use the clean technique to change the dressing at the insertion site
- C. Elevate the head of the bed to 90° to obtain CVP readings
- D. The 0 mark on the manometer should align with the client's right clavicle for the readings
Correct Answer: A
Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.