Nokea
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. “Your urine will be collected in a pouch following surgery.”
- B. “You will have a nasogastric tube after surgery.”
- C. “Your bowel will be visualized with a laparoscope during surgery.”
- D. “You can drink liquids within 24 hours after surgery.”
Correct Answer: A
Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.
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Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply
- A. Offer the opposite breast at each feeding to their
- B. Avoid frequent nursing of the infants
- C. Avoid breastfeeding
- D. Ensure that their hands and breasts are clean
Correct Answer: D
Rationale: Rationale:
D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses.
A is incorrect because alternating breasts is a common practice in breastfeeding.
B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis.
C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.
A client comes to her health care provider’s office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
- A. Initial assessment
- B. Focused assessment
- C. Emergency assessment
- D. Time-lapsed assessment
Correct Answer: B
Rationale: The correct answer is B: Focused assessment. In this scenario, the client's abdominal pain is a known issue, so a focused assessment would be appropriate to gather specific information related to the current complaint. A focused assessment allows the nurse to concentrate on the particular problem at hand, which in this case is the abdominal pain.
A: Initial assessment is not applicable as the client has been seen for this issue before.
C: Emergency assessment is not necessary as the situation does not indicate an urgent or life-threatening condition.
D: Time-lapsed assessment is not suitable because it involves assessing changes over time, which is not the primary concern in this scenario.
In summary, a focused assessment is the most appropriate choice as it allows the nurse to address the client's specific complaint efficiently.
Mr. Reyes has a possible skull fracture. The nurse should:
- A. Observe him for signs of Brain injury
- B. Check for hemorrhaging from the oral cavity
- C. Elevate the foot of the bed if he develops symptoms of shock
- D. Observe for symptoms of decreased intracranial pressure and temperature
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. The written outcomes are designed to meet nursing goals
- B. To encourage the client and family to be involved
- C. To discourage additions by other healthcare providers
- D. Why the nurse believes the outcome is important
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.