Nokea
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus.
- B. Opening the bottom of the pouch, allowing the flatus to be expelled.
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape.
- D. Assisting the client to ambulate to reduce the flatus in the pouch.
Correct Answer: B
Rationale: Opening the bottom of the pouch allows controlled release of flatus.
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Describe the relationship between receptors and neurotransmitters.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
- A. Bowel sounds
- B. Surgical dressing
- C. Temperature
- D. Oxygen saturation
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation. The priority assessment after a cholecystectomy is monitoring the client's oxygen saturation to ensure adequate oxygenation post-surgery. Decreased oxygen saturation can indicate respiratory distress, which requires immediate intervention. Bowel sounds (A) are important but not the priority post-cholecystectomy. Surgical dressing (B) should be assessed, but it is not as critical as monitoring oxygen saturation. Temperature (C) is also important, but ensuring oxygenation takes precedence in the immediate postoperative period.
To communicate with a patient who does not speak the dominant language, the nurse should
- A. Speak slowly and enunciate clearly in a slightly louder voice.
- B. Use gestures and pantomime words while verbalizing specific words.
- C. Use family members rather than strangers as interpreters to increase the patient’s feeling of comfort.
- D. Use a dictionary or phrase books that translate from both the nurse’s language and the patient’s language.
Correct Answer: A
Rationale: Speaking slowly, using gestures, and utilizing translation tools facilitate effective communication. Using family members as interpreters can introduce bias and inaccuracies.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
What would be the best response by the nurse to a quiet and uncommunicative client?
- A. Think over the following questions.
- B. Discuss them with your instructor or peers.
- C. Acknowledge their feelings and encourage expression.
- D. Offer silence and wait patiently.
Correct Answer: D
Rationale: Silence can provide the client with space to open up when they feel ready, fostering trust and rapport.