Nokea
The client with a newly created colostomy is concerned about having satisfying sexual relations. What should the nurse recommend?
- A. Participate in sexual activity only in a darkened room.
- B. Utilize self-gratification for the majority of sexual needs.
- C. Empty and clean the ostomy bag just before sexual activity.
- D. Utilize only the female superior position for sexual activity.
Correct Answer: C
Rationale: Emptying the pouch before sexual activity is recommended to decrease the concern of pouch breakage or leakage; cleaning it will reduce odor.
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The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately?
- A. A serum sodium of 128 mEq/L in a client diagnosed with obstipation.
- B. The client diagnosed with fecal impaction who had two (2) hard formed stools.
- C. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea.
- D. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
Correct Answer: A
Rationale: Hyponatremia (sodium 128 mEq/L) in obstipation risks neurological complications, requiring immediate HCP attention. Formed stools, normal potassium, and moderate diarrhea are less urgent.
The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?
- A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour
- B. Initiate nasojejunal enteral feedings with a low-fat formula
- C. Imipenem-cilastatin 500 mg IV every 6 hours
- D. Up to chair for meals and ambulate four times daily
- E. Position left side-lying with head of bed elevated 30 degrees
- F. Insert a urinary catheter; monitor urine output every 2 hours
Correct Answer: A, B, C, F
Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.
The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy?
- A. Clay-colored stools.
- B. Yellow-tinted sclera.
- C. Amber-colored urine.
- D. WGold-colored urine.
- E. Wound approximated.
- F. Abdominal pain.
Correct Answer: A,B,E
Rationale: Clay-colored stools and yellow-tinted sclera indicate possible bile duct obstruction or jaundice, while abdominal pain suggests complications like infection or bile leak, all requiring HCP notification. Amber urine and approximated wounds are less urgent.