Nokea
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
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To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
- A. Thyroid cancer
- B. Acute laryngitis
- C. Laryngeal cancer
- D. Bronchogenic cancer
Correct Answer: C
Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.
The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.
The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?
- A. Placing the infant under phototherapy
- B. Keeping the infant NPO until the second period of reactivity
- C. Encouraging the mother to breast-feed the infant every 2 to 3 hours
- D. Encouraging the mother to supplement breast-feeding with formula
Correct Answer: C
Rationale: To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium. Breast-feeding should begin as soon as possible after birth while the infant is in the first period of reactivity.
The nurse is assisting a client with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse should take which action to minimize the client's risk for injury?
- A. Clamp the chest tube.
- B. Call the primary health care provider.
- C. Apply a petroleum gauze over the end of the chest tube.
- D. Immerse the chest tube in a bottle of sterile water or normal saline.
Correct Answer: D
Rationale: If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube or, in this case, immersing the end of the chest tube 1 to 2 inches below the surface of a 250-mL bottle of sterile water or normal saline until a new chest tube can be set up. The primary health care provider should be notified but only after taking corrective action. If the primary health care provider is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petroleum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.