Nokea
The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period?
- A. Maintain the client in a semi-Fowler's position.
- B. Assist the client with warm sitz baths.
- C. Administer 30 mL of milk of magnesia to stimulate colostomy activity.
- D. Remove the ostomy pouch as needed so the stoma can be assessed.
Correct Answer: B
Rationale: Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary to be available to change the ostomy pouch to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage. CN: Physiological adaptation; CL: Synthesize
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A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein thrombosis (DVT), the nurse should:
- A. Restrict fluids
- B. Encourage deep breathing
- C. Assist the client to remain sedentary
- D. Use pneumatic compression stockings
Correct Answer: D
Rationale: Pneumatic compression stockings prevent DVT post-surgery by promoting venous return and reducing stasis. Restricting fluids increases viscosity, deep breathing aids respiratory function, and remaining sedentary increases DVT risk.
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis. High-protein (B) may worsen encephalopathy. Low-fat, low-protein (C) is too restrictive. Low-sodium (D) is relevant for ascites, not early cirrhosis.
A 38-year-old female client with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which of the following actions should the nurse suggest?
- A. Apply warm compresses to the affected arm.
- B. Elevate the arm on two pillows.
- C. See the physician immediately.
- D. Schedule an appointment within 2 to 3 weeks.
Correct Answer: C
Rationale: Redness, warmth, and swelling suggest cellulitis, a serious infection in a client with a history of axillary node dissection, requiring immediate medical evaluation.
The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action?
- A. Arrange for a cross-match between the available blood and the client's blood.
- B. Call the other blood banks and ask if they have blood units available with the client’s blood type.
- C. Notify the physician that there is no available blood in the blood bank.
- D. Call the client’s family and tell them that he needs blood.
Correct Answer: A
Rationale: In an emergency, O+ blood can be safely transfused to an A+ client, as O+ is the universal donor for red blood cells. Arranging for a cross-match ensures compatibility and is the most appropriate action. Contacting other blood banks or notifying the physician delays care, and calling the family is inappropriate.