Nokea
The nurse is caring for a client after an ileostomy. The nurse would be MOST concerned if which of the following was observed?
- A. The ileostomy functions without daily irrigations.
- B. The stoma appears to be tight, and there is a decreased amount of stool.
- C. A small amount of mucus is seen around the anal area.
- D. There is weight gain of 5 lb over a three-week period of time.
Correct Answer: B
Rationale: important to report these findings to the physician; may indicate an obstruction or stoma stricture
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A 22-year-old mother of a 4-year-old boy comes to the antepartal clinic. Her second pregnancy has just been confirmed.
During this initial visit, it MOST important for the nurse to
- A. assess the client's feelings about pregnancy, labor, and delivery.
- B. obtain a history of the client's last labor and delivery.
- C. determine how the client's 4-year-old feels about the pregnancy.
- D. identify the client's general health needs.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) important data, priority is the here and now (2) important data, but not priority for first visit (3) important data, need to deal with the mother's needs first (4) correct-optimal opportunity for preventative health maintenance
The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?
- A. Change the IV tubing each time a new IV solution is hung.
- B. Cleanse the IV site with an alcohol swab using long strokes.
- C. Limit manipulation of the cannula at the IV insertion site.
- D. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Correct Answer: C
Rationale: will prevent dislodgment of needle
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client.
The nurse should
- A. identify the client before administering the medication.
- B. administer the medication two hours before the procedure.
- C. administer an enema after administering the medication.
- D. instruct the client to take medication slowly with water.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-appropriate identification of client is the first nursing priority after the order is verified (five 'rights' of medication administration) (2) unnecessary (3) unnecessary (4) unnecessary
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration