Nokea
The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?
- A. I will change my colostomy bag every day.
- B. I should eat a low-fiber diet.
- C. I need to inspect the stoma daily for color and swelling.
- D. I can skip my colostomy care if I feel well.
Correct Answer: C
Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.
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While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?
- A. Endotracheal cuff pressure greater than 25 cm H2O.
- B. Decreased lung compliance during ventilation.
- C. Bilateral crackles with increased secretions.
- D. Restless client who is biting the endotracheal tube.
Correct Answer: D
Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.
A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?
- A. Check blood pressure
- B. Assess heart rate
- C. Monitor respiratory rate
- D. Measure oxygen saturation
Correct Answer: B
Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.
A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct Answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?
- A. Perform hand hygiene before and after handling the catheter
- B. Change the catheter every 72 hours
- C. Apply antibiotic ointment at the insertion site
- D. Irrigate the catheter daily
Correct Answer: A
Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.
The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?
- A. Stand the client to void and run tap water within hearing distance before catheterizing
- B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
- C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
- D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.