Nokea
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
- A. You should be emptying the pouch yourself.'
- B. Let me demonstrate to you how to empty the pouch.'
- C. What have you learned about emptying your pouch?'
- D. Show me what you have learned about emptying your pouch.'
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
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The nurse is caring for a 79-year-old client. Which observation is not normal and should be reported for follow-up?
- A. The client has several brown spots on her cheek and neck.
- B. The client says, 'I move slower than I used to.'
- C. The client is short of breath when walking down the hall.
- D. The client says, 'I have trouble telling the colors of my socks.'
Correct Answer: C
Rationale: Shortness of breath with exertion may indicate cardiovascular or respiratory issues, requiring follow-up. Brown spots, slower movement, and color vision changes are normal aging signs.
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
- A. Recommend a dermatological consult to the MD.
- B. Note the location of the mole and contact the physician via the telephone.
- C. Note the location of the mole and follow-up with the attending physician via the medical record and phone call.
- D. Remove the mole with a sharp's debridement technique, following charge nurse approval.
Correct Answer: C
Rationale: Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.