Nokea
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
- A. She should be able to control evacuation of her bowels.
- B. She should be able to return to a regular diet.
- C. She should be able to resume sexual activity.
- D. She should be able to manage her own care.
Correct Answer: A
Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.
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The nurse is caring for a client with a history of anaphylaxis to peanuts. Which precaution is most important?
- A. Keep an epinephrine auto-injector at the bedside.
- B. Place the client in a private room.
- C. Administer antihistamines daily.
- D. Monitor for respiratory distress every 4 hours.
Correct Answer: A
Rationale: An epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Private rooms, antihistamines, and monitoring are secondary to ensuring rapid emergency response.
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Encourage exercises in the unaffected extremities.
- B. Encourage her to cross and uncross her legs.
- C. Check neurological and circulatory status of the affected leg hourly.
- D. Place a trochanter roll along the upper thigh of the affected leg.
Correct Answer: B
Rationale: Exercising the unaffected extremities will prevent contractures and emboli. Crossing and uncrossing the affected leg after surgery can dislocate the joint. Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A. Avoid a high-fiber diet
- B. Continue to apply ice packs
- C. Take a laxative daily to prevent constipation
- D. Use a sitz bath after each bowel movement
Correct Answer: D
Rationale: Sitz baths after bowel movements promote healing and relieve pain post-hemorrhoidectomy by keeping the area clean and reducing inflammation. High-fiber diets are encouraged, ice packs are typically used earlier, and laxatives may be prescribed but are not the priority.
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
- A. Report the findings to the physician
- B. Assist the client to do range of motion exercises
- C. Check the client's potassium level
- D. Administer the as-needed dose of phenytoin (Dilantin)
Correct Answer: A
Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.
The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
- A. Chocolate
- B. Fresh vegetables
- C. Lean meats
- D. Whole grains
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.