Nokea
The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
Correct Answer: E,D,C,B,A
Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
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The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
- A. Tell the client to avoid a tub bath for 48 hours
- B. Tell the client to expect clay-colored stools
- C. Tell the client that she can expect lower abdominal pain for the next week
- D. Tell the client to report pain in the back or shoulders
Correct Answer: D
Rationale: Pain in the back or shoulders post-laparoscopic cholecystectomy may indicate referred pain from residual CO2 or complications, requiring prompt reporting.
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
- A. Pain at the site
- B. Warm fingers
- C. Pulses rapid
- D. Paresthesia of the fingers
Correct Answer: D
Rationale: Paresthesia of the fingers suggests possible nerve compression or compartment syndrome, which requires immediate reporting to the doctor.
The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds
- B. Keep the head of the bed elevated at night
- C. Wear socks and gloves when going outside
- D. Recognize clinical manifestations of thrombosis
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising thrombosis risk. Teaching clients to recognize thrombosis symptoms (e.g., swelling, pain) is critical for early intervention.
Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?
- A. The fundus is firm and 3 finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.
The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:
- A. Increased weight
- B. A sore throat
- C. Difficulty in sleeping
- D. Changes in mood
Correct Answer: B
Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.