Nokea
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.
You may also like to solve these questions
An elderly client is admitted to the unit with a temperature of $100.2^{\circ}$, urinary specific gravity of 1.032, and a dry tongue. The nurse should anticipate an order for:
- A. An antibiotic
- B. An analgesic
- C. A diuretic
- D. An IV of normal saline
Correct Answer: D
Rationale: The symptoms (fever, high urinary specific gravity, dry tongue) indicate dehydration. IV normal saline is the priority to rehydrate. Antibiotics require infection confirmation, analgesics address pain, and diuretics worsen dehydration.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).
- A. Which arterial blood gas result is expected in a client with chronic COPD?
- B. pH 7.40, PaCO2 40 mmHg, PaO2 90 mmHg.
- C. pH 7.32, PaCO2 50 mmHg, PaO2 70 mmHg.
- D. pH 7.45, PaCO2 30 mmHg, PaO2 95 mmHg.
- E. pH 7.30, PaCO2 35 mmHg, PaO2 85 mmHg.
Correct Answer: B
Rationale: Chronic COPD causes CO2 retention, leading to a compensated respiratory acidosis with low pH (7.32), high PaCO2 (50 mmHg), and low PaO2 (70 mmHg) due to impaired gas exchange. Normal or acute values are incorrect.
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should be turned every two hours, with the cast's surface exposed to the air.
Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.