Nokea
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer's
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.
You may also like to solve these questions
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections
- B. Vitamin B6 injections
- C. An antibiotic
- D. An antacid
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is needed for Vitamin B12 absorption. Since the stomach lining produces less intrinsic factor after gastric surgery, the client cannot absorb B12 orally. Therefore, B12 injections are necessary to bypass the need for intrinsic factor. Vitamin B6 injections (B) are not indicated for pernicious anemia. Antibiotics (C) and antacids (D) are not relevant to the treatment of pernicious anemia.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
- A. Take a deep breath when I tell you and breathe normally while I remove the tube.
- B. Take a deep breath when I tell you and bear down while I remove the tube.
- C. Take a deep breath when I tell you and slowly exhale while I remove the tube.
- D. Take a deep breath when I tell you and hold it while I remove the tube.
Correct Answer: C
Rationale: The correct answer is C because instructing the client to take a deep breath and slowly exhale while the tube is being removed helps relax the client's throat muscles, making the removal process smoother and less uncomfortable. Taking a deep breath and holding it (choice D) could lead to increased tension and resistance, while bearing down (choice B) may cause the client to push against the tube, making the removal difficult. Instructing the client to breathe normally (choice A) doesn't provide specific guidance on how to facilitate the removal process.
The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stool less watery?
- A. Pasta
- B. Boiled rice
- C. Bran
- D. Low-fat cheese
Correct Answer: C
Rationale: Rationale:
C: Bran is a high-fiber food known to add bulk to stool, thus making it less watery in individuals with ileostomy.
A: Pasta and B: Boiled rice are low-fiber foods that may not help thicken stool.
D: Low-fat cheese is not specifically known to thicken stool.
In summary, choosing high-fiber foods like bran can help thicken stool, while low-fiber foods like pasta, boiled rice, and low-fat cheese may not have the same effect.
A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?
- A. Erythrocyte sedimentation rate
- B. Serum bilirubin
- C. Hemoglobin
- D. Blood urea nitrogen
Correct Answer: C
Rationale: The correct answer is C: Hemoglobin. In hepatitis, there is destruction of red blood cells, leading to decreased hemoglobin levels. This is a specific indicator of the disease. The other choices are incorrect because A (ESR) is a nonspecific marker of inflammation, B (serum bilirubin) is elevated in liver dysfunction but not specific to hepatitis, and D (BUN) is a measure of kidney function, not related to hepatitis. Hemoglobin, being directly affected by the disease process in hepatitis, is the most specific indicator among the options provided.