Nokea
The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.
- A. Describe the dietary intake, including types of foods.
- B. Include cruciferous vegetables in the diet daily.
- C. Decrease fluid intake to 1200 mL per 24 hours.
- D. Prick the colostomy stoma pouch with a pin.
- E. Limit intake of gas-producing carbonated sodas.
- F. In the bathroom, open the pouch clamp to release gas.
Correct Answer: A,E,F
Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.
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A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.