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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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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.
Why should the nurse closely monitor older adults when they are receiving IV therapy?
- A. Because their defense mechanisms are less efficient.
- B. Because they are prone to fluid overload.
- C. Because they are prone to increased renal efficiency.
- D. Because they have inadequate intake of dietary fiber.
Correct Answer: B
Rationale: The correct answer is B because older adults are more susceptible to fluid overload due to decreased kidney function and other physiological changes.
The patient experiences sudden pain in his right calf while sitting at home. He is diagnosed with deep vein thrombosis (DVT). The first intervention is to
- A. Apply ice packs to the affected area every 4 to 6 hours.
- B. Increase dietary intake of foods rich in vitamin K.
- C. Monitor platelet counts daily.
- D. Use intermittent warm soaks of the affected area.
Correct Answer: C
Rationale: Monitoring platelets is crucial when anticoagulants are administered.
What is the main risk factor for developing presbycusis?
- A. Age
- B. Noise exposure
- C. Genetics
- D. All of the above
Correct Answer: A
Rationale: Age is the primary risk factor for presbycusis, a form of age-related hearing loss.
Which member of the surgical team does not scrub in the OR?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse remains outside the sterile field to assist with supplies.