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During the immediate postoperative period after a colostomy, which stoma appearance requires the licensed practical nurse to contact the supervising registered nurse immediately?
- A. Brick red with slight moisture
- B. Dusky moderate edema
- C. Pink with slight oozing of blood
- D. Red with no stool produced
Correct Answer: B
Rationale: A dusky stoma (B) indicates ischemia, requiring immediate reporting. Brick red (A), pink with oozing (C), and no stool (D) are normal post-colostomy findings.
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A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:
- A. CNS depression that accompanies xanthine derivatives
- B. CNS stimulation that sometimes accompanies xanthine derivatives
- C. The anticholinergic effects of aminophylline
- D. Cardiovascular depression that can accompany xanthine derivatives
Correct Answer: B
Rationale: Aminophylline, a xanthine derivative, can cause CNS stimulation, leading to nervousness and shakiness. It does not typically cause CNS or cardiovascular depression or anticholinergic effects.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
A postoperative client is having difficulty voiding. Palpation of the bladder indicates that the bladder is full. What should the nurse do initially?
- A. Ask the physician for a catheterization order
- B. Pour water over the client's perineum
- C. Encourage the client to take deep breaths
- D. Administer pain medication
Correct Answer: B
Rationale: Pouring water over the perineum stimulates the micturition reflex, aiding voiding non-invasively. Catheterization, breathing, or pain medication are secondary.
The nurse is caring for a client who had a colostomy. Which comment by the client indicates that she is showing an interest in learning about her colostomy?
- A. Why did this problem have to happen to me?'
- B. What is the bag of water for?'
- C. When will I get rid of this thing?'
- D. The doctor didn't really do a colostomy.'
Correct Answer: B
Rationale: Asking about the bag's purpose shows curiosity and readiness to learn about colostomy care. Other comments reflect denial, frustration, or lack of engagement.
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
- A. I have such a hard time with the pain in my feet and knees.
- B. I have had loose stools for the last few months.
- C. My children say I keep my apartment too warm.
- D. I have a hard time at night because the lights are all big and fuzzy.
Correct Answer: C
Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.